Magnitude and Factors Affecting the Fertility Desire of People Living with HIV Infection in Ethiopia, A Cross Sectional Study

Human Immune Deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) is the major health, social and political problem in worldwide which has taken a distressing effect in many societies. It ranks fourth among the leading causes of death worldwide and first in Sub-Saharan Africa. Approximately 33.4 million people worldwide were living with HIV in 2010 and 2 million deaths ,out of this only about 40% knows their HIV status and 10 million are waiting for treatment and 5 million people are on treatment. Sub-Saharan Africa remained the most affected region in the global AIDS epidemicwhich is 22.4 million and whereas inEthiopia980000of people living with HIV [1,2].


Introduction
Human Immune Deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) is the major health, social and political problem in worldwide which has taken a distressing effect in many societies. It ranks fourth among the leading causes of death worldwide and first in Sub-Saharan Africa. Approximately 33.4 million people worldwide were living with HIV in 2010 and 2 million deaths ,out of this only about 40% knows their HIV status and 10 million are waiting for treatment and 5 million people are on treatment. Sub-Saharan Africa remained the most affected region in the global AIDS epidemicwhich is 22.4 million and whereas inEthiopia980000of people living with HIV [1,2].
The majority of new human immunodeficiency virus (HIV) infections that occur in children worldwide occur among children born to HIV positive mothers, who acquire the HIV infection from their mothers.Major strides have been made in recent years in expanding access to antiretroviral therapy (ART) and comprehensive care for HIVinfected men and women in sub-Saharan Africa .For many people living with HIV, ART enables a return to normal life including a resumption of sexual activity and a new or renewed desire for children. This desire is often fueled by the strong societal and traditional values attached to parenthood in sub-Saharan Africa and is further enhanced by the development of increasingly effective antiretroviral regimens to reduce the risk of HIV transmission from an infected mother to her newborn or breastfeeding child.The success of highly active antiretroviral therapy (HAART) in reducing morbidity and mortality from HIV/ AIDS has been widely documented. Consequently, many HIV-infected persons are now living longer, healthier, and more productive lives.The infection rate among pregnant women in Sub-Saharan Africa is also alarmingly high, where 90% of global new child infections through mother-to-child transmission (MTCT) [3][4][5][6].
Since access to antiretroviral therapy has improved quality of life and survival for HIV infected people, many will contemplate child bearing. Identification of contextual determinants of decision to have children among HIV positive couples is useful for designing of policies. African woman are being infected at an earlier age than men, and the gap in HIV prevalence between them continue to grow. At the beginning of the epidemic in sub-Saharan Africa, women living with HIV were vastly at number than men. But today, there are on average 13 infected women for every 10 infected men in 2010. The majority of all new HIV infections are occurring among women of childbearing age and recent evidence shows that pregnant women may be at a higher risk of HIV infection than lactating women or non-pregnant, non-breastfeeding women. While antiretroviral treatment (ART) has improved the health status of people living with HIV, new challenges to their sexual and reproductive health (SRH) needs and their ability to prevent secondary HIV infections have risen..The increasing feminization of the global HIV epidemic is widely recognized this is because in 1985 almost 35% ofthe totalHIV infected population were women. The majority of women living with HIV are in their reproductive age, highlighting the critical need to address issues surrounding reproductive and sexual rights, including in relation to childbearing and pregnancy. Acrosssectional study conducted in South Africa one-third of HIV-infected individuals receiving ART would like to become pregnant in the future and high prevalence of fertility desires among men [7][8][9].
As EFY(Ethiopian Fisical Year) 2003 Annual report shows a total of 8,365 HIV-positive mothers received ART(Anti Retro Viraltherapy) treatment which contributing to 9.3% of those eligible (90,311). Despite the increase in ANC(Antenatal care) coverage observed in the past years, PMTCT coverage is still low (9.3%) and there are 1,150 ever enrolled HIV infected individuals at Woreilu Health Center in February 2010 [10,11].

Study design, study area and period
A Facility based cross sectional study design was employed and data was collected using iterviwer administered structure quesionnaire (quantitative method) and further supplemented by in depth interview (qualitative method). The study was conducted in Woreilu Health Center found in town of Woreilu Woreda, Amhara Region from January 2012 to May 2012. Based on the 2007 Census conducted by the Central Statistical Agency (CSA) of Ethiopia South Wollo Zone has a total population of 2,518,862. It has 3 government hospitals, 132 Health centers and 469 Health posts. Geographically, the Woreda is located 500 km away from Addis Ababa. Woreilu is the district city of Woreilu Administrative Woreda., and it has 4 Health centers and 20 Health Posts. Among all health centers woreilu health centers is the only which provide ART service in the woreda

Source population
The source population was all HIV positive individuals who visited ART clinic of the health center their age were 18 years old or above for men and reproductive age group (15-49 years old) for women and appeared during the study period.

Sample size determination
Quantitative method: The sample size was determined using single population proportion determination formula. A previous study conducted in South Wollo [6] revealed that the proportion of fertility desire of married men and women living with HIV was18.3% with expected margin of error(d) 4% just to maximize my sample size and improve the precision of my study given the cost and time, 95% confidence interval (Z α /2 )n=(Z α /2 ) 2 P (1-P)/d 2 Z=1.96 (95% confidence interval), d=0.04 margin of error ,P=0.18 then the sample size was=354.4, Non-response rate 10%=35.44+354.4, Total=392 participants Qualitative method: For qualitative method the number of people planed to be interviewed was 12 (Six females and Six males). But the selection continued until the point of redundancy and eight respondents, equal number of males and females were interviewed by the data collectors.
Sampling procedure: For quantitative study, particapants were selected using systematic random sampling technique from regestration book and convinnet sampling methed was used to select particpants for qualitaitive study.
Data collection procedure: Interviwer administered Structured questionnaire was applied as a quantitative data collection instrument. Three Diploma nurses as data collectorand one BSC nurse as supervisor from Kelalla Woreda were hired to collect data. To maintain data quality the questioner was preteted on nearby Degollo Health center on5% of the client and extensive supervision was made daily by the supervisor during data collection. In addition, an open ended semi-structured interview guide was prepared and used for the qualitative study. Each interview was carried out by data collectors and field notes was taken.

Data management and analysis
Quantitative data analysis: Quantitative data was entered using SPSS version 16 and exported to STATA version 11 for analysis. Exploratory data analysis (EDA) was made before computing any statistical analysis. Consequently, outliers, Multi-collinearity and Independence of observationswere checked up. The univariate analysis such as percentages, ratios, frequency distributions and appropriate graphic presentations, summary tables and charts was used to describe the data used in the study. In the bivariate analysis χ 2 tests of association was used using p-value 0.20. Based on the results of bivariate analysis, i.e. using variables found significant in the bivariate case binary logistic regression model was fitted to examine the effect of the independent variables on the fertility desire. The presence of potential confounder and interactions between fertility desire and other exposure variables was assessed using stratification and multivariate techniques.Finally, variables which was show significant association in the bivariate analysis with p value <0.2 was included in the final logistic regression model and 95% confidence interval for all odds ratio was used.
Qualitative data analysis: The qualitative data that was found from in-depth interview was analyzed by applying thematic analysis approach. Once the data is collected, it was transcribed and pattern of common ideas was listed. Then, related data to the classified patterns was identified and combined in to sub themes.
Ethical consideration:Ethical approval was gained from the ethical review committee of the Mekelle University, college of Health science and Letter of permission was obtained from Woreilu Woreda Health office before conducting the study. Participants who included in the study were informed about the aim and duration of study, then oral consent was obtained from each participants.

Quantitative result
Socio demographic characterstics of respondent: A total of 392 patients were enrolled and completed the baseline interview during the study period. Among the total study subjects 206 (52.55%) were females. Majority of respondents 43.37% were aged between 25-34 years. Marital wise, the majority were married contributing about 182 (46.43%). The predominant religion was Muslim 208 (53.06%).
Regarding their educational status, more than one fourth of the study subjects 129(32.91%) were illiterate Of all interviewed patients, 212 (54.16%) of them were not using any family planning method. Largest portion 326 (83.16%) of respondents knew about MTCT out of these 281 (71.68%) of them knew the availability of medication used to prevent mother to child HIV transmission.It is claimed that, health professionals and Public media were identified as major sources of information about mother to child transmission and prevention accounting 212 (54.10%) and 12 (3.06%) respectively. More than half 232 (59.18%) of them believed that, the medication for PMTCT can actually reduce the transmission (Table 1). Table 2, fertility desire was disaggregated based on the different sociodemographic characteristics. Generally, as described above, 155 (39.54) respondents have desire to have children while the rest have no desire. Of all study participants, 87 (46.77%) of male and 68 (33.01%) of female respondents had fertilitydesire.

Fertility desire with other characteristics of study subject:
Among those whose partners wish to have children, 85 (73.28) of them have fertility desire. As expected, more than half 102(57.63%) of family planning users don't want to have child. Conversely, out of those respondents who were not using family planning methods, large proportion of them 133 (62.74%) had no fertility desire.
Regarding ART enrollment, majority, 60% of respondents who have started receiving ART were found to have no fertility desire. The study demonstrated that, as the time spent after the respondent knew his/her HIV status gets increased, the fertility desire showed little increment. Similarly, as the ART treatment duration was greater than a year, the fertility desire increased from 32.9% to 41.2%.Variation was observed in the fertility desire of partners who have HIV test and who don't have HIV test, contributing 48% and 40% respectively,while there was no difference in the fertility desire of partners' with positive or negative HIV test result. (Table 3).

Determinants of fertility desire (Bivariate Analysis):
Among the socio-demographic characteristics of respondents, sex, age and marital relationship were largely found to be associated with fertility desire even after adjusting for other selected socio-demographic variables.
Multiple logistic regression analysis: Multiple logistic regression analysisidentify; marital status, number of alive children and partners fertility desir as predictor variables of fertility desir.
The odds of fertility desire for respondents' who were single, widow/ widowed and divorced were 0.158 (95% CI=0.035, 0.716 p-values <0.017), 0.042 (95% CI=0.004, 0.469 p-values <0.010) and 0.140 (95% CI=0.028, 0.714 p-values <0.018) respectively times less likely to desire fertility when compared with those respondents who were married. While those respondents who had partner but not married were 1.933 (95% CI=0.537, 6.949) times more likely to desire fertility when compared with married respondents. Comparing fertility desire of *None married partener means in this research those who are capul and living together but not married official

Qualitative result
Eight respondents, equal number of male and female, participated in the interview. The respondent's age ranges from 17-42 years. Respondent's educational status varied from cannot read and write to diploma in secretarial science. Out of Eight respondents three were farmer, one student, two merchant and two house wife. Five respondents were Muslim and the rest three were orthodox. Three out of Eight had children. Six of them start ART and the rest did not and all of them use family planning after they diagnosis.

Desired fertility
Respondents' reasons for fertility desire were asserted. Out of eight respondents, 2 females and 2 males, total of four respondents reported child desire. Most expressed were to have at least one or two children, availability of ARV treatment and unchanged fertility desire because of HIV/AIDS.    * Significant association (p ≤ 0.05) ** None married partener means in this research those who are capul and living together but not married officially

medication to prevent the transmission. This is practically I have seen from my neighbors. "
A 23 years old man with no children expressed "I knew I'm positive and my couple is too, I'm quite sure the baby's going to be positive from his mother. The medication, that is said to be available to reduce the chance of transmission, in capable to eliminate and to reduce because, I have practiced that those who use the prophylaxis but their children were infected with the virus. So, how can it be possible to protect the child from getting infected? In addition, my wife is not in good health thus pregnancy will further compromise her health since she carry and feed the fetus for nine months so, we have discussed and agreed not have child, even we have negative opinion on those who wants child being infected with the virus. "

Discussion
To our knowledge, this is the first research in WoreiluWoreda to document the fertility desire of people living with HIV/AIDS in a quantified way. As shown in the result section, this study assesses magnitude of fertility desire among people living with HIV infection and identifies predictor variables of fertility desire for people living with HIV infectioninWoreiluWoreda.
The chi-square statistic from -2 log-likelihoods shows that the model fitted well the data. But the value of pseudo R-square 0.35 was small which indicates there are the proportion of variation explained by explanatory variables in the model is not adequate. This indicates there are other variables which are not included in the study that well explain the variation in fertility desire.
From the total study subjects, 155 (39.54%) respondents have fertility desire. Likewise, a study done in Addis Ababa revealed out of 414 study subject 165 (39.9%) had desire to have children in the future [1]. In addition another comparable result was found in a crosssectional study done in Addis Ababa, which showed thatover all 40.2% of HIV positive individuals receiving care in Addis Ababa desired to have children [12]. On the other hand, the proportion of this study population who desire children was higher than those reported in studies from Amhara region South wollo which is a facility based crosssectional study [6] and conversely a study done in Canada, revealed that 69% of the respondents would like to give birth in the future [13,14]. This discrepancy may be explained by lack of knowledge about PMTCT in South Wollo while the respondents in Canada may be more aware about PMTCT and may have improved health status as compared to the study subjects considered in this study.
The finding showed that, 87(46.77%) of male respondents and 68 (33.01%) of female respondents had fertility desire. Furthermore, sex was significantly associated with fertility desire in that female respondents were found to be less likely to have fertility in the future as compared with male. However, a study done in northern Nigeria shows that of all 167 (65.5%) females and 52(61.2%) males expressed a desire to have more children [9]. This difference may be due to women in Nigeria may be financially strong as well as their literacy might be better than women in our country.
Different factors may influence the fertility desire of individuals. Though, the quantitative study doesn't compare fertility desire among PLHIV and clients without HIV, in the qualitative result opposite ideas were raised regarding the effect of HIV infection on the need to have child. Some of them claimed that being HIV positive has negative effect on the fertility desire of individuals due to fear of transmission to the child, lack of knowledge of PMTCT and considering pregnancy as risk condition for individuals live with HIV while others explained that as ART improves our health condition and it also prevents mother to child transmission, we wanted to have children.
Among others, age and marital status were found to be significantly associated with fertility desire of individuals. The finding showed that the fertility desire of respondents with age category greater than 35 was significantly lower as compared to those respondents younger than 35 years with p-value <0.05. In addition, widowed and divorcedrespondents have significantly lower fertility desire as compared to other categories of marital relationship while the fertility desire of respondents who have non married partners were found to be four times more higher when compared with married patients. This finding is also supported by the qualitative finding as some widowed respondents claimed that, as their wife/husband was passed away, they don't want to marry another person and get birth.
Coming to the respondents' partner fertility desire, out of those who have fertility desire majority 85 (73.28%) of respondents partner's wanted to have child. The study also revealed that, it was significantly associated with the need to have more children. Respondents whose husbands/wives/partners don't want to have child, had significantly lower fertility desire as compared to those respondents whose partners need more child, with p value 0.00001. Once again this finding is supported by the qualitative finding that most respondents who wanted to have child explained that their partner has also fertility desire.
According to this study, there was no statistically significant association between fertility desire and knowledge of PMTCT, though it seems that patients who were not aware of PMTCT has lower fertility desire. Similarly, the study confirmed that, duration of HIV diagnosis, enrolment to ART care and duration of ART treatment have no significant association with fertility desire. Conversely, the qualitative finding revealed that, having knowledge about PMTCT has positive influence towards their fertility desire as compared to those who were not aware of PMTCT. Furthermore, respondents in the qualitative study explained that, starting ART treatment improves their health status, thus their fertility desire increases.

Conclusionand Recommendation Conclusion
The most important factors identified asdeterminenat of fertility desire were marital relationship, partner fertility desire and respondents number of alive children. Findings from the analysis reveal that respondents with non married partner were four times more likely to have children in the future which is somewhat different our anticipation prior to analysis. Perhaps this is due the fact that those had not married partner want to have child/children as result of their partner relationship. Another important finding of this study is that the respondents who have less two children and whose partner desired to have fertility they tend to have fertility. In general, the result of this study revealed that a high number of HIV positive men and women desired children and reproductive decisions in peoples living with HIV are not only affected by their HIV status but depends on different predictor factors. Those who desire fertility are having no children or have less number of children, married or in relationship and have partners who also desire children. • Since, data indicated that 83% knew PMTCT but only 59% knew that medication provided for PMTCT reduce the transmissionhigh number patients were not aware of PMTCT service, the concerned body including the health facilities should conduct advocacy and sensitization about PMTCT to all patients who visited the health center especially at MCH and ART clinics.