Fertility Desires of HIV-positive Women Attending Care and Treatment Clinics (CTC) in Urban Areas in Tanzania

Introduction: Reproductive concerns by People Living with HIV (PLHIV) are matters that are important for both individual and general public health. We described fertility desire among HIV-positive women attending Care and Treatment Clinics (CTC) and determined factors for having such a desire to get children in urban areas of Dar es Salaam and Dodoma in Tanzania. Material and Methods: Cross-sectional study for which primary data were collected in a random sample of women of reproductive age (15-49 years) after accessing HIV care and treatment services. A survey was conducted among HIV-positive women receiving anti-retroviral treatment to document service needs, service quality, and fertility preferences. A Univariate model was used to examine the relationship between the dependent and the independent variables, and all associations were taken into account in the final model. Results: Among 691 participants, 282 (40.8%) women living with HIV have fertility desire. Women aged above 25 experienced a reduction in the odds of fertility desire by 56% (p - value =0.003) compared to the reference group of women aged 25 years or less. Fertility desire was predicted to have two times as much growth with 1 to < 3 years (p-value=0.02) and 5 or 5+ years ( P value =0.01) time lapse since the debut of ART, compared to the group of women who were on ART for 3 years but less than five years. Conclusion: Our data has not only reconfirmed the importance of ART and PMTCT services to PLHIV but also contributed to evidence on their value addition in terms of the creation of resilience to normal fertility family life after debut HIV diagnosis.


INTRODUCTION
Globally, there are 37.7 million people living with Human Immunodeficiency Virus (HIV); women and girls account for more than half of all new infections [1].In Tanzania, 1 million women aged 15 years and above are HIV positive, with young women aged 15-24 years being twice more likely to be living with HIV than their male counterparts [2].Although the reproductive roles are important social and biological determinants of health across sexes, women might be particularly disadvantaged, and further, in those living with HIV, it might lead to increased vulnerability to maternal-related challenges, including the risk of HIV transmission to the fetus [3][4].Fertility desire, which refers to an individual or a couple's intention to have children in the future, among People Living with HIV (PLHIV) as such is the subject of interest using health facility-based data in resource-limited settings.
Given the considerable burden of HIV prevalence in women of childbearing and sexually active age, concerns related to further biological children are issues of public health importance [5][6].Whereas interventions are definitely necessary, both within and beyond the health system, there remains considerable heterogeneity across different settings and countries on some key factors of a wish to have another child in the future, as exhibited by married or cohabiting couples regardless of their HIV status, fertility desired [7].
Meta-analyses of 50 and 20 articles showed that the PLHIV who are on Anti-Retroviral Treatment (ART) are males younger than 30, married/ cohabiting, have received secondary education or above, and are childless have a higher prevalence of fertility desire [8][9][10] and, respectively, no association neither with ART, sex or educational attainment [11].Elsewhere, amongst Women Living with HIV (WLHIV), a higher proportion was more likely to be associated with no desire, whereby factors associated with such a desire were age, education level, and household wealth status [12][13].
In Tanzania, increased fertility desire was associated with HIV disclosure, good perceived health status, and CD4 count ≥200 cells for both sexes [14] and also, if someone was male, had primary education, was married/cohabitating, and had fewer children [15] or not having them at all [16].The need for further analytical efforts on this area of childbearing desire by Women Living with HIV (WLHIV) is justified, in this case, by current limitations on the availability of evidence in Tanzania as well as an observed extent of heterogeneity of what is so far known on the subject.

MATERIAL AND METHODS
The study included HIV-positive women aged 18-45 years who visited 25 health facilities with CTC in Dodoma and Dar es Salaam, who were randomly selected right after accessing HIV care and treatment services.Dar es Salaam is Tanzania's largest city and commercial center, with a population of over 6 million people.The city is one of the busiest places in East Africa and has a high concentration of trade, manufacturing, and so other service-related activities.Dodoma is the national capital and home of the legislative assembly, with a population of 2,083,588 people (2012 estimate).It is located in central Tanzania, covers 41,311 square kilometers (15,950 square miles), and is divided into seven administrative districts, including Dodoma Municipal, in Fig. 1.It is a map of Tanzania within East Africa, showing the location of Dar es Salaam and Dodoma and the visited health facilities.
Validated standard questionnaires were used to conduct exit interviews, whereby date of interview, level of health facility, administrative categories up to street level where the women came from, birth date, date of start of ART, demographic questions, satisfaction with CTC and Prevention of Mother-to-Child Transmission (PMTCT) services, family planning services at the CTC, pregnancy and plan for more children questions were asked.Fertility desire was considered as an outcome variable, while the consideration of independent variables was based on literature review.Factors influencing the fertility desire among HIV-positive women were isolated and related to the kind of questions asked during the exit interview.Therefore, age of the women, marital status, duration on ART, education level, income generation, home belonging, relation with the household head, HIV status of the last born, confidentiality on participant sero status with Health Care Provider (HCP), How do HCP treat participant during service provision, Sero status of participant's partner and How many Households (HHs) are there in the area participants are living as well as number of people living in participant house and are eating together were considered as the independent variables.Univariate analysis was done on all proposed independent variables, and all those variables that showed association were promoted into the final multivariate model.Sampling weight was not applied, analysis tools /software were STATA version 15, and Microsoft Word was used to document the findings.
The research ensured participants' safety through compliance with international and local ethics guidelines.Ethical approval from the relevant Institutional Review Board (IRB) at Ifakara Health Institute and from the National Institute for Medical Research in Tanzania and permission to visit health facilities from the President's Office, Regional Administration, and Local government were pursued.Interviewers were trained to work with the participant respectfully and safely with emphasis on ensuring written informed consent is obtained, and risks are minimized as much as possible.Precautions were taken to eliminate risks of breach of confidentiality by using unique identifiers for study participants instead of names and the use of password-protected computers during data collection and analysis.

Description of the Study Population
Table 1 presents the descriptive information of the population under the study.There were 691 HIVpositive women interviewed during their CTC visits in Dar es Salaam 345 (50%) and Dodoma 346 (50%) regions with Council distribution as followed, Dodoma Municipal Council (346, 50.07%),Kinondoni (83, 12.01%), Ilala (125, 18.09%), Temeke (34, 9.99%), Ubungo (69, 12%) and Kigamboni (34, 4.92 %) with mean age of 35.5 years.All but half, 323 (46.7%) of them were married or cohabiting, and 615 (89%) of them had been to school, predominantly with a primary level of education 403 (65.53%).The prevalence of family planning use was 52%, and all but few said that their HIV status was known to their partners.The prevalence of desire to have another baby was 40.8%, and nearly half (323, 46.74%) had 5 or more years of experience in ART.
Table 2 is a summary of the measure of the relationship between fertility desire among HIV-positive women with various socioeconomic and other factors at the Univariate level, whereas the results of the factors influencing fertility desire among HIV-positive women in the full model are shown in Table 3. Eight out of sixteen variables in the data set were not included in the final model because their significance level was relatively low, as estimated during the stepwise regression process.
Women who had 3-4 biological children experienced a reduction in the odds of fertility desire by 55% (p-value <0.01) and by 95% (p-value =0.02), overall and in Dar es Salaam respectively.Fertility desire was predicted to grow by about 1.57 (p-value =0.024) times with not receiving education on family planning.Being divorced, separated, or widowed was associated with a reduction in the odds of fertility desire by 56% (p-value <0.01), and women in age categories of 25 to < 45 and 45+ years' experienced a reduction of 56 % (p-value <0.01) and 87% (p-value =0.023) as compared to those aged less than 25 years.Fertility desire was predicted to grow by twice as much in women with experience of 1 to < 3 (OR=2.061,p-value =0.017) and 5+ years (OR=2.125,p-value <0.01) on ART as compared to those with less than 1 year but shown no association amongst those who had 3 to < 5 years' duration of ART use.When considered alone, those who had 3 to < 5 years' experience with ART (Not shown) experienced a reduction in the odds of fertility desire not only with having 3-4 biological children as before (93%, p-value <0.01) but also amongst those who had work within last 12 months (89%, p-value =0.04) and only in women aged 45+ years' experienced reduction of 94 % (p-value =0.018) but did not show association in those aged 25 to < 45 years as before, as compared to those aged less than 25 years.

DISCUSSION
We have reported a 40.8% prevalence of fertility desire amongst PLHIV women in Tanzania settings along with decreasing fertility desire amongst PLHIV women, with increasing age and particularly after 45 years old.The fact that women in age categories of 25 to < 45 and 45+ years experienced a reduction of 56 % (pvalue <0.01) and 87% (p-value =0.023) as compared to those aged less than 25 years might suggest that adherence to ART and PMTCT services by PLHIV have got value addition in keeping the good state of PLHIV woman and hence bring back such desire to somewhat an average level of what is expected in the general population [17].However, this study did not inquire if the desire was a wish or an intention, nor did it inquire whether any effort was made towards having another baby, such as attempting consultation from a PMTCT clinic, meeting with a gynecologist, and so on, which could have helped in distinguishing a wish from an intention.
Duration of using ART has shown a somewhat varying pattern of fertility desire, with those with 1 to 3 years and 5 or more years having significant affirmative desire but not amongst those who have been on ART for 3 to less than 5 years.The health system is such that once pregnant and tested positive, a woman would instantly have her debut ART, and after delivery, an exposed child undergoes dried blood spot (DBS) until 18 months of age before final HIV status can be concluded.Such a 2-year time-lapse, almost of observation time, might influence fertility desire for the middle category of 3 to less than 5 years since they started ART services.

CONCLUSION
In the context of heterogeneity literature based on some key factors for fertility desire and interventions necessary, both within and outside the health system, to guide inclusion in practice/policies, this study complements previous work findings that indicated that fertility desires were associated with ART.The data offers further indications about the need for profound consideration of reproductive health services amongst Women Living with HIV, not only for their individual health needs but also for public health gains at large.The ART and PMTCT services may, as such, have value addition in establishing resilience to normal fertility family life after a first HIV diagnosis.

Fig. 1 .
Fig. 1.Map of Tanzania, showing the location of Dar es Salaam and Dodoma and health facilities visited.Source: ArcGIS desktop output by Aleswa Zebedayo (author)

Table 2 .
Factors Influencing Fertility Desire Among HIV-positive Women Univariate Modal

Table 3 :
Factors Influencing Fertility Desire Among HIV-positive Women Multivariate Modal