Fertility and HIV Infection : Fertility Decision-making Challenges of Mutually- Disclosed Discordant Couples and Young People

Abstract: Background: Sexuality and reproduction in mature generalised HIV epidemics pose significant dilemma to both HIV infected and negative people. Sexually active young people and HIV serodiscordant couples are faced with difficult decision-making about procreation and HIV transmission. Insufficient data exists about fertility decision-making and how to handle sexuality and fertility among the HIV-infected youth and mutually disclosed discordant couples. Aim: To explore the influence of HIV on fertility decision-making among young people and people in HIV-discordant relationship in Uganda Methods: The four studies used qualitative (focus group discussions - study I, II, and III) and quantitative methods (semi-structured questionnaire - study III and IV). We explored the views of the youth on reasons for high fertility in Uganda and how decisions are made among the youth in the general population (study I) and among HIV-infected youth (study II). A cross sectional study (study III) assessed fertility decision-making among the discordant couples, and a prospective cohort (study IV) assessed how HIV-infected and negative youth sustain their fertility decisions over a period of one year. Thematic and content analysis were used for qualitative data and uni-variate, bi-variate and multivariate analysis for the quantitative data. Results: Patriarchy, culture and religion contribute to sustaining high fertility in Uganda (paper I). The majority (57%) would like to have children but have to grapple with the dilemma of HIV transmission to partner (paper II and III). Less than a half (44%) among the HIV-infected youth compared to two thirds (61%) among the HIV-negative youth made a consistent fertility decision, OR = 0.52 (0.38, 0.70). In total, 24% among the HIV-negative and 18% among the HIV-infected continued to use contraception throughout the year, OR 0.63 (0.41, 0.98), while 12% and 28% among the HIV-negative and infected respectively did not use contraception, OR 2.80 (1.80, 4.36) (paper IV). Conclusions: Young people in central Uganda are still strongly influenced by the patriarchal, cultural and religious norms with the male gender enjoying a superior position. This compels women to desire many boys for their security and happiness (paper I). Many HIV serodiscordant couples in central Uganda desire to have children and are planning to conceive but the highest desire for children is among the young people (paper III, IV). The desire to have children hinders safe sex practice among HIV sero-discordant couples (paper II). The discordant couples committed to condom use have to risk HIV transmission, or look for a sero-concordant partner to get children. Others seek high-risk concurrent partnerships for children and sexual pleasure (paper II). HIV infected youth are not empowered to practice or sustain consistent contraceptive use or adopt preventive strategies (paper I, IV). The current dialogue with health workers is not increasing contraceptive use, especially among the HIV-infected youth (paper IV). Implications: Uganda s cultural norms still favour high fertility and having HIV infection cannot remove the quest to fulfil patriarchal obligations. If not assisted, PLHIV will continue to practice high-risk sex to reproduce. A multi-sectoral approach uniting cultural, political and public institutions is needed to design programs that may stem the HIV epidemic. Strengthening family planning services should include planning for conception for the PLHIV. Critically, in addition to the need for the cultural re-learning processes to desire less children, we need to introduce low-cost harm reduction techniques for reproduction (timed intercourse, sperm washing) to assist PLHIV who want to have children to do so with minimal HIV transmission.