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AIDS Behav (2009) 13:S38S46 DOI 10.

1007/s10461-009-9550-1

ORIGINAL PAPER

Fertility Intentions and Reproductive Health Care Needs of People Living with HIV in Cape Town, South Africa: Implications for Integrating Reproductive Health and HIV Care Services
Diane Cooper Jennifer Moodley Virginia Zweigenthal Linda-Gail Bekker Iqbal Shah Landon Myer

Published online: 3 April 2009 Springer Science+Business Media, LLC 2009

Abstract Tailoring sexual and reproductive health services to meet the needs of people living with the human immuno-deciency virus (HIV) is a growing concern but there are few insights into these issues where HIV is most prevalent. This cross-sectional study investigated the fertility intentions and associated health care needs of 459 women and men, not sampled as intimate partners of each other, living with HIV in Cape Town, South Africa. An almost equal proportion of women (55%) and men (43%) living with HIV, reported not intending to have children as

D. Cooper (&) J. Moodley Womens Health Research Unit School of Public Health & Family Medicine, University of Cape Town, Anzio Road Observatory, 7925, Cape Town, South Africa e-mail: Diane.Cooper@uct.ac.za V. Zweigenthal Western Cape Department of Health, Cape Town, South Africa L.-G. Bekker Desmond Tutu HIV Centre, Department of Medicine and Institute of Infectious Diseases & Molecular Medicine, University of Cape Town, Cape Town, South Africa I. Shah Department of Reproductive Health and Research, World Health Organisation, Geneva, Switzerland L. Myer Infectious Diseases Epidemiology Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa L. Myer Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA

were open to the possibility of having children (45 and 57%, respectively). Overall, greater intentions to have children were associated with being male, having fewer children, living in an informal settlement and use of antiretroviral therapy. There were important gender differences in the determinants of future childbearing intentions, with being on HAART strongly associated with womens fertility intentions. Gender differences were also apparent in participants key reasons for wanting children. A minority of participants had discussed their reproductive intentions and related issues with HIV health care providers. There is an urgent need for intervention models to integrate HIV care with sexual and reproduction health counseling and services that account for the diverse reproductive needs of these populations. Keywords HIV Reproductive intentions Inuencing factors HAART South Africa

Introduction Reproduction poses dilemmas for people living with HIV (PLWHIV) and for public health and clinical care providers. Unprotected sexual activity carries risks for sexual transmission and vertical transmission of HIV. Women living with HIV may also face increased risks during childbirth (Berer 1999; McIntyre 2005). At the same time, many PLWHIV continue to be sexually active and some have strong desires for biological children (Cooper et al. 2007; Myer et al. 2007) which entails unprotected sexual intercourse. Over the past decade, near universal access to prevention of vertical HIV transmission programs (PMTCT), HAART and increasing availability of assisted conception

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methods have shifted the reproductive terrain for PLWHIV in developed countries (Thornton et al. 2004). These advances have given hope for enhanced life expectancy for PLWHIV and led to dramatically reduced risks of partner and infant infection with HIV (Williams et al. 2003; da Silveira Rossi et al. 2005). There has been increasing advocacy for respect of PLWHIVs reproductive rights (Gruskin et al. 2007) and a more nuanced approach to health advice to PLWHIV regarding fertility planning (Williams et al. 2003). Sub-Saharan Africa is the center of the global HIV epidemic with nearly two-thirds of those living with HIV/AIDS residing in this region. Sixty percent of PLWHIV in Africa are women in their reproductive years (UNAIDS 2008) South Africa has had one of the fastest growing HIV epidemics and the highest prevalence rates are in women aged 2529 years (21%) and 3034 years (18%) (Department of Health 2006). This age range coincides with the beginning or peak of their reproductive lives. Hence it is critically important to enhance reproductive service provision to assist PLWHIV in both preventing unwanted pregnancies or conceiving and giving birth as safely as possible in developing country contexts. Previous research on the reproductive health of HIVinfected women and men has highlighted diversity in perspectives on future fertility intentions and how these may change over time. Important factors include individual desires and concerns, partner and societal expectations, provider attitudes and medical interventions (PMTCT and HAART). Evidence also suggests that PLWHIV in developing countries often do not have sufcient information about contraception and parenting options (Orner et al. 2008; Cooper et al. 2007; Paiva et al. 2003, 2002; Nebie et al. 2001). Biomedical considerations generally predominate in providers approach to HIV infection and reproductive decision-making, hampering health services in dealing sensitively with the reproductive health care needs of HIV-infected individuals and adequately meeting their reproductive health care needs (Harries et al. 2007). Despite these insights, there are still few data on the prevalence of fertility intentions and inuencing factors. The primary aim of this study was to inform the improvement of reproductive health service counseling and service delivery among HIV-infected women and men attending HIV care services in Cape Town. The objectives were to explore fertility intentions; reasons for intentions and factors inuencing these, among women and men living with HIV, attending public sector health services. In addition the study investigated whether they had had discussions about their reproductive intentions with health care providers at these services.

Methods Study Design, Setting and Population The study consisted of a cross-sectional survey conducted between May and September 2006 at PMTCT, VCT, general HIV care and HAART services in two public sector health centers in a large residential area in metropolitan Cape Town. Both health centers serve predominantly black, urban and peri-urban, working class communities and were selected as study sites as they are situated in a residential area with high HIV prevalence1 and are broadly representative of the types of services available for HIV positive individuals in this setting. Eligibility Criteria Male and female clients diagnosed with HIV attending these health services at the study sites and aged 18 years and above were eligible for participation in the study. There was no upper age limit applied in the recruitment of either women or men. Further inclusion criteria were that they were willing to: discuss certain aspects of their HIVinfection, as related to the study topic and objectives with an interviewer; have the discussion recorded anonymously on a questionnaire and have basic medical information abstracted from their medical records. Sample Size and Statistical Power Calculations As this was a preliminary exploratory study which aimed to describe the prevalence of fertility intentions in different populations of HIV-infected individuals, a sample size of 460 HIV positive individuals was used to allow the estimation of a 33% prevalence of positive fertility intentions with an approximate condence interval of 5%. The original enrolment targets from the various HIV care facilities, were 145 respondents, equally divided by sex, attending HIV care (non-HAART) and HAART, respectively and 85 respondents attending VCT and PMTCT (women only), respectively. These targets were adjusted during the study to account for variations in actual numbers of male and female clients that attended each of these services during the study period.

The antenatal HIV prevalence was estimated to be approximately 29% in this residential area (personal communication, LG Bekker, Desmond Tutu HIV centre, University of Cape Town; 5th April 2006).

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Sampling and Data Collection Individuals were selected to participate at random by researchers using random number sequences and registers of patients attending each service that day. Male and female clients interviewed were not selected on the basis of being intimate sexual partners. The survey was conducted, by same-sex interviewers, experienced in quantitative interview techniques and who had received additional study methods training for this specic survey. Interviewers were employed by the tertiary academic institution responsible for implementing the study and had no professional relationship with the respondents interviewed. Interviewers administered standardized structured questionnaires with pre-coded answers, in face-toface interviews. Interviews were conducted in the subjects mother tongue and lasted approximately 30 min. The questionnaire included the following key domains: (1) socio-demographic background, (2) current intimate partnership status, (3) length of time of relationship with main intimate partner, (4) number of biological children, (5) disclosure of HIV status, (6) time since HIV positive diagnosis, (7) current CD4 T cell, (8) pregnancy history since HIV diagnosis of respondent or male respondents female partner, (9) current pregnancy status of respondent/ respondents partner, (10) current fertility intentions, (11) attitudes towards alternatives to biological parenting (both formal and informal alternatives such as adoption, fostering or caring for a relatives child) and (12) experience of reproductive counseling at the service he/she was attending. With respect to fertility intentions the following question was asked: Which of the following statements best describes your thinking about you/your main partner having a child. The choice of answers offered were: I want to have a child right now; I may want to have a child in the next 12 months; I may want to have a child sometime in the future; I do not know/am unsure about whether I may want to have a child in the future; and I have decided that I do not want to have a child in the future. Conrmation of participants HIV status was conrmed with their medical records. Duration of HIV diagnosis, CD4 counts and length of time on HAART were elicited both through participants self-report and subsequently conrmed by medical records where this data was on record. Data Analysis Data were analysed using Stata version 10.0 (College Station, Texas, USA). Means with standard deviations were used to describe the distributions of normally distributed variables, while medians and interquartile ranges were used for non-normal distributions. Bivariate analyses used

t-tests, rank-sum tests, and chi-square tests (replaced by exact tests for sparse data) for means, medians and proportions, respectively. In bivariate and multivariate analyses, we included dont know/unsure of wanting to have a child at present with the no categories to facilitate analysis as the dependent variable in regression models. The multivariate model was built in an iterative process which examined each of the independent variables of interest; included in the nal model were variables which demonstrated appreciable associations with the outcome of interest, or whose inclusion/exclusion from the model altered associations involving other variables (i.e., confounding variables). Final models were checked using standard regression diagnostics for logistic regression; interaction (effect measure modication) was examined only for gender, which was an a priori possible interaction of interest. All statistical tests were two-sided at alpha of 0.05. Descriptive associations between key factors are presented as odds ratios. We assessed the association of factors, using unconditional multiple logistic regression to adjust for confounding and estimated odds ratios. Crude and adjusted odd ratios are presented using 95% condence levels. Ethical Considerations Ethical approval for the study was given by the Research and Ethics Committee at the University of Cape Town and the Ethical Review Committee of the World Health Organization. Respondents informed written consent was obtained for participation in the study and interviews were conducted in private rooms at the study sites.

Results A total of 459 respondents were interviewed. The overall study response rate was 93%. There were 30 (6%) refusals. The main reasons for refusal were respondents feeling too ill to be interviewed or not having time to stay on and be interviewed after their consultation with a health care provider. More women (n = 285) than men (n = 174) were interviewed. The median time since diagnosis for both women and men was 12 months (IQR, 348). Table 1 provides the background characteristics of respondents and details of enrollment of participants by HIV care facility. As can be seen in Table 1, women were signicantly younger, more educated, had a higher household income and less likely to be in a current stable intimate sexual relationship with a main partner who was the parent of their one of their children, than men.

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AIDS Behav (2009) 13:S38S46 Table 1 Socio-demographic background characteristics of respondents HIV care site (%) PMTCT (women only) VCT HIV care (pre-HAART) HAART treatment facility Median age (years) (IQR) Employed (%) IsiXhosa speaker (%) Median highest level of education Live in shack/informal dwelling (%) Household income C approx US $ 150/month (%) Median number of biological children (IQR) Has reportedly had child previously die of AIDS (%) Currently taking care of non-biological children (%) Currently in a stable intimate heterosexual relationship (%) Median duration of current intimate relationship (years) (IQR) Current main intimate partner is parent of a child(ren) (%) Previous PMTCT (women only) HAART use Median most recent CD4 count (IQR) 96 (21) 64 (14) 111 (24) 188 (41) 32 (2738) 92 (20) 449 (98) Grade 10 226 (49) 256 (56) 1 (12) 86 (19) 59 (13) 345 (75) 4 (27) 152 (44) 131 (46%) 187 (41) 96 (34) 38 (13) 39 (14) 112 (39) 29 (2534) 60 (21) 279 (98) Grade 11 136 (48) 188 (66) 1 (02) 58 (20) 35 (13) 229 (81) 3 (26) 82 (36) 131 (46%) 112 (39) 26 (15) 72 (41) 76 (44) 36 (3243) 32 (18) 170 (98) Grade 9 90 (52) 68 (39) 2 (12) 28 (16) 24 (14) 116 (67) 5 (310) 70 (60) 75 (43)

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Total (n = 459)

Women (n = 285)

Men (n = 174)

P-value

\0.001 0.549 0.999 \0.001 0.442 \0.001 0.006 0.269 0.668 0.001 0.001 \0.001 0.578

207 (96344) 252 (142380) 140 (59242) \0.001

Men were more likely to have had more children than women. Similar percentages of women and men lived in informal dwellings, had a child who had reportedly died of AIDS and were caring for a non-biological child. The vast majority of the 229 women (88%) and the 116 men (87%) currently in a stable intimate heterosexual relationship had disclosed their HIV positive status to their main intimate partner and to a family member (77% of 285 women and 84% of the 174 men). Only a third of women and men had disclosed their HIV status within their communities.

Alternative Parenting Options A minority of women (18%) and men (9%) reported a willingness to consider formal adoption as an alternative to having a biological child. However, a signicant minority among both female and male respondents expressed a willingness to consider caring for a family members child as an alternative to biological parenting (35 and 44%, respectively, P = 0.045). Fertility Intentions Table 2 shows women and mens reported fertility intentions. Fifty-seven percent of men and 45% of women reported being open to the possibility of having a child. Those with fertility intentions are sub-divided into those wishing to do so immediately, within the next year, those with future intentions and those who were undecided. Factors Associated with Fertility Intentions Table 3 shows that in a bivariate analysis, when disaggregated by sex, age, being currently in a main sexual

Pregnancies Post-HIV Diagnosis Among women in HIV care (non- HAART; n = 36), 11% reported becoming pregnant after being aware of their HIV status. All these pregnancies were reportedly unintentional. Only half of these women had entered a PMTCT program during this reported pregnancy. Among women on HAART (n = 104), 9% reported having been pregnant since commencing HAART; of these 30% of pregnancies were reportedly unintentional.

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S42 Table 2 Current fertility intentions, by subgroup Overall (n = 459) Current thinking about having a child Open to the possibility of having a child I want to have a child right now I may want to have a child in the next 12 months I may want to have a child sometime in the future I do not know/am unsure Not planning to have a child
a b

AIDS Behav (2009) 13:S38S46

On HAART (n = 188) P = 0.189 (on HAART vs. not)

Not on HAART Median time since (n = 271) dx (months) P = 0.001a

Median CD4 (n = 371) P = 0.654a

Women (n = 285) P \ 0.001b

Men (n = 174)

229 (50) 23 (5) 14 (3) 111 (24) 81 (17) 230 (50)

91 (48) 13 (7) 8 (4) 43 (23) 27 (14) 97 (52)

138 (51) 10 (4) 6 (2) 68 (25) 54 (20) 133 (49)

12 36 18 12 24 6

204 204 125 193 240 242

129 (45) 11 (4) 9 (3) 43 (15) 66 (23) 156 (55)

100 (57) 12 (7) 5 (3) 68 (39) 15 (9) 74 (43)

Rank-sum test comparing median values across categories of fertility intentions Exact test comparing distribution of fertility intentions between women and men

Table 3 Factors associated with fertility intentions Overall Desire a child (n = 148) (%)a Median age (IQR) Employed Median highest level of education (grade) (IQR) Live in shack/informal dwelling Household income C approx US$ 150 Mean number of own children (SD) Has reportedly had child die of AIDS previously Currently taking care of non-biological children Currently in a main sexual/ intimate relationship Mean duration main sexual/ intimate relationship (years) (SD) Current main sexual/intimate partner is parent of childa Mean months since HIV diagnosis (SD) On HAART Mean months on HAART (for those on HAART) (SD)
a b

Females Do not desire a child (n = 311) 32 (2739) 61 (20) 10 (811) 138 (44) 178 (57) 1.7 (1.4) 53 (17) 42 (14) 230 (74) 6.0 (5.9) P-value Desire a child (n = 63) 27 (2531) 13 (20) 11 (911) 35 (56) 43 (68) 0.8 (0.8) 16 (25) 7 (11) 57 (90) 4.3 (3.0) Do not desire a child (n = 222)

Males P-value Desire a child (n = 85) 36 (3129) 18 (21) 9 (611) 53 (62) 35 (41) 1.2 (1.2) 17 (20) 10 (12) 58 (68) 5.3 (4.7) Do not desire a child (n = 89) 37 (3246) 14 (16) 8 (611) 37 (42) 33 (37) 2.2 (1.5) 11 (12) 14 (16) 58 (65) 9.0 (8.0) P-value

31 (2737) 31 (21) 10 (811) 88 (59) 78 (53) 1.0 (1.0) 33 (22) 17 (12) 115 (78) 4.8 (4.0)

0.504 0.803 0.264 0.003b 0.367 \0.001b 0.202 0.654 0.420 0.060

30 (2636) 0.002b 47 (21) 0.999 10 (912) 0.291 101 (46) 145 (65) 1.5 (1.3) 42 (19) 28 (13) 172 (77) 4.9 (4.7) 0.198 0.764 0.004b 0.290 0.999 0.020b 0.369

0.021 0.435 0.914 0.007b 0.642 \0.001b 0.216 0.515 0.748 0.003b

46 (40) 24.4 (27.5) 64 (43) 10.9 (10.1)

106 (46) 28.0 (30.6) 124 (40) 17.8 (16.2)

0.302 0.223 0.543

13 (23) 29.9 (29.4) 31 (49)

69 (40) 27.3 (29.8) 81 (36) 19.0 (16.4)

0.025b 0.539 0.080 0.082

33 (57) 20.2 (25.4) 33 (39) 8.7 (6.6)

37 (64) 30.0 (32.8) 43 (48) 15.7 (15.9)

0.569 0.038 0.224 0.023

0.002b 13.3 (12.4)

Percentages are based on those participants reporting a current relationship Factors signicantly associated with greater fertility intentions = P \ 0.05)

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relationship, having fewer children and having a partner who was not the biological parent of one of their children were signicantly associated with fertility intentions for women. For men living in an informal dwelling, having fewer children as well shorter duration of their main intimate relationship were signicantly associated with fertility intentions. Table 4 shows the multivariate analysis of signicant determinants for future childbearing. Overall (see model A), being male, on HAART, having fewer children and living in an informal settlement were all independently signicantly associated with having fertility intentions. There was no association between fertility intentions by HIV care service type in the crude analysis, except for with the PMTCT service. In the adjusted analyses this association did not persist. When determinants for future childbearing were examined separately for women and for men (see models B and C), for women, being on HAART and having fewer children, remained independently signicantly associated with fertility intentions. For men, only living in an informal settlement remained independently signicantly associated with fertility intentions. Reasons for Fertility Intentions The commonest reported reason for women (n = 63) and men (n = 85) wanting to have a child was wishing to do so while their health still permitted (21 and 39%, respectively). This was followed by wanting at least one child/ more children (16 and 26%, respectively). Further reasons for women were upon marriage and replacing a child who had reportedly died of AIDS (13 and 6%, respectively). Only 1% of men reported desiring to replace a child who had reportedly died of AIDS. Twice the proportion of men (10%) compared with women saw sufcient nancial means as important in their decision-making, whereas half

the proportion of men (8%) compared with women saw marriage as a reason to have children. An identical proportion of men and women (6%) saw having children as fullling life dreams. Other reasons included for women (33%): if they had the nancial means to do so and pressure from their families/male intimate partners; and for men (10%), a female partners preference and if they could nd a way to do so safely. Womens primary deterrent to future childbearing among those not wanting to have a child (n = 222) was also for HIV-related health reasons32% compared with only 10% of men. The majority (68%) of these women reported fearing pregnancy would cause progression in their illness. The commonest reason deterring men from having children was unrelated to HIV. Men reported not wishing to have more children (n = 85) because they had sufcient children (21%) or due to having insufcient nancial means (20%). Further discouraging factors for both men and women included fears of infant or partner infection or children becoming orphans. Some stated they were too confused or coming to terms with their own illness to think about childbearing or because of advanced age. Among women, 4% reported being unmarried as a reason not to have children, whereas for men this did not emerge as a reason. Inuences on Fertility Intentions The majority of women (62%) and men (65%) had discussed their fertility intentions with a main intimate partner. Twenty-four percent of women and 55% of men reported being very strongly inuenced in their childbearing desires by a partners desires. A minority of women (24%) and men (20%) had discussed their fertility intentions with a family member and 44% of women and 65% of men reported being inuenced by family opinions. Most women (51%) perceived negative community attitudes

Table 4 Multiple logistic regression model predicting the relative odds of intending to have a biological child among HIV-infected women and men Model Aa: Overall (women and men) OR Age (continuous) Sex female = 1; male = 2 On HAART Level of education (continuous) Total living children (continuous) Lives in shack (vs. formal house
a b

Model Bb: Women OR 0.69 2.41 0.99 0.59 1.40 95% CI 0.901.02 1.284.54 0.841.16 0.400.87 0.772.55

Model Cb: Men OR 0.98 0.78 0.98 0.58 2.38 95% CI 0.931.03 0.401.54 0.8701.10 0.871.10 1.214.67

95% CI 0.941.01 3.018.56 0.902.26 0.901.08 0.470.74 1.152.81

0.97 5.08 1.43 0.98 0.59 1.80

P-value for interaction between gender and HAART use (separate model not shown) in predicting fertility intentions, 0.021 Model A shows the overall main effects for women and men together, adjusted for all covariates shown Models B and C show the effects for women and men respectively, adjusted for all covariates shown

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towards HIV-positive individuals intentionally childbearing compared with 25% for men. However, men (24%) were four times more likely to be inuenced by negative community attitudes than women (7%). Consultation with Health Care Providers about Fertility Intentions A relatively small proportion of respondents (19% of women and 6% of men) had consulted a doctor, nurse or counsellor in HIV care about fertility intentions. There was a trend towards greater consultation with health care providers among older women. In addition women attending HIV care or HAART services were signicantly more likely to have discussed their fertility intentions with health care providers than women attending PMTCT (44 vs. 10%; P \ 0.001). A third of women and two-thirds of men reported wanting fertility intention discussions with health care providers if given an opportunity. Women with childbearing intentions were more likely to want discussion with health care providers (49 vs. 27%; P \ 0.001) as were women attending PMTCT and HIV care (non-HAART) compared with women on HAART (41 vs. 28%; P \ 0.000) and younger women (49 vs. 26%; P \ 0.000).

Discussion Our ndings show almost equal proportions of women (55%) and men (43%) living with HIV not planning to have children as open to the possibility of having children (45 and 57%, respectively). This indicates the need for reproductive planning counseling for clients in HIV care settings in order to meet PLWHIVs diverse reproductive intentionsfor those wishing to have children and those wishing to avoid having children. In addition, the study quanties some of the common reasons for PLWHIVs fertility intentions which need to inform individual HIV care client counseling. The proportion of women living with HIV in this study who may wish to have children appears to be higher than that reported among women living with HIV in developed countries (Smits et al. 1999; Chen et al. 2001; Magalhaes et al. 2002; Kirshenbaum et al. 2004). South Africa remains a pro-natal society and motherhood forms a central feature of womens social identity and status and not having children may diminish womens social status (Dyer et al. 2002). The ndings in this study showing continued desires to have biological children among men living with HIV, echo ndings of the few studies conducted elsewhere (Chen et al. 2001; Paiva et al. 2003; Sherr and Barry 2004), as well as our own prior studies (Cooper et al. 2007) Mens greater intentions to have children than women may be due

to a desire to leave something of themselves, their name and lineage behind when they die, reported in other studies of HIV-infected men in South Africa and in other patrilineal societies (Cooper et al. 2007; Doyal and Anderson 2005; Paiva et al. 2003) Fertility as proof of virility and a feature of South African adult male social identity has also been reported in other studies (Dyer et al. 2004; Cooper et al. 2007). This analysis found a signicant interaction between gender and HAART use in predicting fertility desires, with HAART use having a stronger positive impact on fertility intentions among women (OR 2.41) than men (OR 0.78). This nding, together with the gender differences found in key reasons for wanting children, points to the complex role of gender in shaping fertility intentions, with potentially different determinants of fertility intentions for women and men. Clearly the role of gender as an important overarching factor in shaping fertility intentions among HIV-infected individuals requires further investigation. In crude analyses, these data suggested that duration of HAART was inversely associated with fertility desires, as both women and men who had been on HAART for shorter periods reported greater fertility desires, on average, compared to individuals on HAART for longer periods. Although this association did not persist in multivariate analysis, it does point to the potential inuence of duration of HAART on fertility desires, an issue which requires further investigation. The nding that use of HAART promotes fertility intentions among women living with HIV corroborates ndings from developed countries (Williams et al. 2003) and emerging evidence from developing countries (Kaida et al. 2006). As HAART availability and access improves and an increasing number of young PLWHIV enter lifelong treatment, the impact of HAART on promoting childbearing intentions is likely to escalate. Policy-makers and health care providers need to anticipate these potentially increased fertility intentions in developing specic reproductive counseling messaging for those at different stages of HIV care. The study ndings conrm anecdotal reports from adoption agencies that formal adoption of children is unlikely to be a favoured option among South African PLWHIV desiring children. However, care of a relatives child could be an alternative to formal adoption. Extended family care arrangements for children due especially to patrilineal cultural norms and physical and social movements arising from migrancy, uid partnership arrangements or orphaned children are common in Southern Africa (Bray 2003). Existing community and cultural practices in this regard could be explored with PLWHIV during reproductive counseling on potential alternative options to biological parenting (de Bruyn 2005).

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The small proportion of women or men living with HIV who had consulted with health care providers regarding fertility intentions is cause for concern. This concern is heightened by the nding that 11% of women (non-HAART) had been pregnant since their HIV diagnosis and all these pregnancies were reportedly unintended. The close on a third of women who had had an unintended pregnancy since commencing HAART is also worrying. Clearly interventions to address these gaps are needed both in the broader reproductive health services and within HIV care settings. An absence of reproductive discussions and easy access to contraceptive measures may lead to pregnancies occurring in the most unsafe conditions and clients desires to prevent or discontinue pregnancies will not be met. This further underscores the importance of creating a service environment within the continuum of HIV care that meets SRH service needs and improves reproductive counseling and service provision. International protocols (WHO 2006) guiding counseling and service provision for women desiring and wishing to avoid pregnancy will need to be adapted, tested and evaluated in developing country contexts. Guidelines for counseling men are urgently needed. Advice for those desiring pregnancy is complex and will require substantial scientic, health and popular consultation. The ndings speak to the need for safer conception methods to be explored and formulated in each specic developing country context. These results should be interpreted in light of some data limitations. This study was cross-sectional rather than longitudinal and therefore unable to capture the potentially changing fertility intentions of PLWHIV in this setting, over time. The inuence of timing of HIV diagnosis, along with the nature of the care received, on fertility intentions requires further research attention. In addition, the study results are specic to one setting in South Africa; although this context is broadly representative of other urban and peri-urban primary care settings in South Africa. Further research is needed in less resourced rural areas with poorer health care infrastructure and potentially different patient and provider attitudes and proles. Moreover, the ndings reect the views and experiences of PLWHIV who attend health care services, and may differ from samples of individuals who are outside of the health care system. In addition, combining data from clients of PMTCT, VCT, and HIV care/HAART care service sites may have introduced some selection bias. It is also possible that the complexity of this topic may manifest itself in participants giving certain responses that were socially desirable. We attempted to counter this by making every effort to ensure a condential and relaxed interview atmosphere featuring strong rapport between researchers and respondents, and in a setting separate from the health care services they received.

The strengths of this study include the further insights gained into the range and magnitude of factors inuencing fertility intentions of women and men in this very high HIV prevalence region of sub-Saharan Africa. It provides new insights on the fertility intentions and associate health care needs of men living with HIV in the context of international recognition that SRH services must target men too.

Conclusion Our data highlight the importance of developing locallyappropriate reproductive health service policies and interventions for women and men living with HIV. Guidelines formulated and counseling protocols developed should address contraceptive needs and fertility desires within the specic context of individuals and their intimate main partners HIV status and within developing country circumstances. These ndings provide a useful basis for adapting and revising existing international draft guidelines for counseling of women. It provides new data for developing counseling guidelines for men. It raises the critical importance of examining the feasibility of on site-location of key reproductive health services in a variety of HIV care service and treatment settings. It is currently contributing to initiatives in Cape Town for greater integration of HIV and SRH services. While models for the integration of tuberculosis care and treatment are being tested in the public sector in South Africa, little attention has been given until now to models for integration of reproductive health care and these ndings underscore urgent redress of this situation through SRH-HIV integration intervention models.
Acknowledgments This study was funded by the UNDP/UNFPA/ WHO/World Bank Special Programme in Human Reproduction, World Health Organization (grant number A45100), the South African Medical Research Council and the University of Cape Town. We are grateful to the eld staff, Nthuthu Manjezi and Pumeza Ngubane and to Penny Mgwigwi for data entry; to the Western Cape Provincial and City of Cape Town Health Departments; the health services where the study was conducted and participants. Our thanks to study consultants, Professors Zena Stein and Lesley Doyal and Dr Joanne Mantell as well as to Maria de Bruyn (Ipas, North Carolina) for insights on the subject and comments on the study instrument.

References
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