The relationship between HIV status and women’s fertility is complex, both biologically and behaviorally. These secondary analyses have shown that, after controlling for other factors in the multiple logistic regression models, the differences in fertility for the last 5 years between HIV seropositive women as compared to seronegative women were not statistically significant. However, the desire for more children in the future is lower among HIV seropositive women aged 20 to 39 compared to HIV seronegative women in Rwanda in 2010.
The relationship between HIV and fertility
The literature about the relationship between HIV infection and fertility is conflicting. The notion that HIV would lead to a stark decrease in fertility has been challenged by evidence that HIV infected women actually have more children than their HIV seronegative peers [13]. A study conducted in Kenya in 2010 showed an increase in fertility in HIV infected women due to an increased mortality in children which led HIV infected women to have more children [14]. However, the increase in fertility in HIV seropositive women may only be true for those women who are still in the early stage of their infection. There is increasing evidence suggesting that HIV infected women, particularly women with advanced HIV infections or AIDS, are less fertile than HIV uninfected women [15].
One possible explanation for no significant association between HIV and fertility in 2010 is the scale-up of ART. In Rwanda, it was estimated that 85% of HIV infected adults in need were on ART in 2010 (compared to 44% in 2005), and the median CD4 cell count at ART initiation among adult patients increased from 153 cells/mm3 in 2005 to 277 cells/mm3 in 2010 [Unpublished dissertation by Dr. Jean Pierre Nyemazi (2012) Outcomes of adult patients on Antiretroviral Therapy from 2004 to 2010 in National University of Rwanda, School of Public Health]. Thus expanded access to ART in Rwanda may explain the lack of significant differences in fertility that we observed in this analysis. Recent studies have reported an independent effect of ART on increasing pregnancy incidence over time in women on treatment compared with ART-naıve women [5, 6, 16]. In several settings where antiretroviral therapy has been scaled-up, pregnancy and births rates among HIV seropositive women have significantly increased [17]. The improved individual health through the availability of ART may result in improved sexual drive, influencing the behavior of HIV seropositive women [18]. Women on treatment may feel healthier, more optimistic about the PMTCT interventions, more positive about their own and children’s futures, and therefore engage in unprotected sexual activity and be more inclined to become pregnant [19].
Another possible explanation for the lack of a significant difference in fertility between HIV seropositive and HIV seronegative women in 2010 is the emphasis that Rwanda has put on promoting access and use of family planning services. Over the last 10 years, the country experienced a remarkable increase in modern contraceptive use. The contraceptive prevalence rate increased from 17 to 52% between 2005 and 2010 [11, 12]. Unmet need for family planning declined from 38 to 19%. The infant mortality rate has decreased from 105 deaths to 50 deaths per 1000 live births, and the total fertility rate dropped from 6.1 to 4.6 births [12, 20]. Thus in addition to increased fertility of HIV seropositive women, there may also be a greater drop in fertility among HIV seronegative women due to use of modern contraceptive methods.
A third potential explanation is that there is no relationship between HIV and fertility in Rwanda, which is supported by the results of the 2005 analysis. However, given the large improvements in survival with HIV, the lack of relationship in 2005 is likely influenced by survivor bias; women who were so sick they could not or chose not be become pregnant did not survive to be measured.
The relationship between HIV and the desire for more children
HIV infected women between 20 and 39 years of age were significantly less likely to want more children in the future than those not infected with HIV in 2010. This was similarly shown in some studies [21, 22], but not all [23]. There are several hypotheses for this finding. In the context of high service coverage, women infected with HIV have monthly contact with the health system through pre-ART or ART care to obtain medication. Therefore, with integrated HIV care and treatment services with family planning services, it is highly conceivable that through regular contact with the health system, infected women have increased awareness about the benefits of spacing and small family sizes thus decreasing their desire for more children. More research is needed to explore the plausibility of this hypothesis.
A competing hypothesis is that the lower desire for children among HIV seropositive women may be born from stigma or fear. In other studies, reasons for HIV infected women not wanting another child included the need to provide for their living children; fear that their poor health may prevent them from taking care of an additional child; the fear of leaving the child orphaned; the fear that they may not have any family support to raise the child; the fact that they were not yet fully convinced about the efficacy of antiretroviral triple therapy in mitigating MTCT; and fear that the physical demands of pregnancy and childbirth could negatively impact their own health [18, 22, 24].
We did not observe a similar effect between HIV and fertility desire in the 2005 secondary analysis. However, this can reflect both survivor bias, since very few people were on HIV treatment at the time, and the very low prevalence of women who knew their HIV status at that time (11.6%) [12].
Limitations
This study used data available through two recent RDHSs. With the cross-sectional nature of the data collection, it is impossible to ascertain the sequence of outcomes and exposures, specifically the length of HIV infection, whether or not a woman knew her infection status (either at the time of the survey or the time of pregnancy), and whether or not she was accessing HIV care. Our hypothesis that access to ART contributed to the non-significant difference in fertility rates between HIV infected and HIV uninfected women relies on the assumption that HIV infected women knew their status and accessed HIV care and treatment services. This is plausible in 2010 when an estimated 80% of eligible individuals in need were on ART, but tenuous in the full 5 years under study as these map to years of scale-up of the ART program. The amount that ART is contributing to non-differential fertility rates can be further explored by repeating this analysis with the 2015 RDHS underway at the time of this analysis, and the 2013 Rwanda AIDS indicator survey. The hypothesis that knowledge of HIV status decreases desire for more children (either through increased family planning knowledge or because of stigma/fear) hinges on the assumption that a woman knew her status at the time of the RDHS data collection. This is a plausible assumption given that in 2010, 77.2% of respondents had ever had an HIV test and 38.6% had a test in the last 12 months [11]. Another limitation resulting from use of secondary data was that not all variables contributing to the relationship between HIV and fertility were available. Specifically, data on past STIs and antiretroviral therapy use are important confounders that were unavailable for this analysis. We recommend that future iterations of the RDHS collect symptoms of common STIs to explore these hypotheses further, though current DHS policy prevents directly asking respondents to disclose HIV status by naming use of ART.