摘要：Objectives. We investigated the impact of HIV status on fertility desires in Uganda. Methods. We surveyed 1594 women aged 18 to 49 years visiting outpatient services at Mbarara Regional Hospital, from May through August 2010. Of these, 59.7% were HIV-positive; 96.4% of HIV-positive women were using antiretroviral therapy (ART). We used logistic regression models to examine relationships between HIV status and fertility desires, marital status, household structure, educational attainment, and household income. Results. Among married women, HIV-positive status was significantly associated with a lower likelihood of desiring more children (27.7% vs 56.4% of HIV-negative women; χ2 = 39.97; P < .001). The difference remained highly significant net of age, parity, son parity, foster children, education, or household income. HIV-positive women were more likely to be poor, unmarried, single heads of household, in second marriages (if married), living with an HIV-positive spouse, and supporting foster children. Conclusions. We found a strong association between positive HIV status and lower fertility aspirations among married women in Uganda, irrespective of ART status. Although the increasing availability of ART is a tremendous public health achievement, women affected by HIV have numerous continuing social needs. Before the availability of antiretroviral therapy (ART) in Africa, women infected with HIV not only had reduced fecundability, 1–4 but also reduced fertility aspirations as many women, men, and health providers were opposed to continued childbearing by persons infected with HIV. 5–7 Qualitative studies reported that HIV-positive women were generally anxious to prevent conception, 5,6 and a majority of both men and women were planning fewer children because of AIDS. 8 In one study, only 10% of HIV-positive home-based care clients reported that they wanted more children. 9 Fertility aspirations varied by context and location, 5,10,11 but they were diminished by the perceived risk of perinatal transmission, 5,11 fear of dying and leaving children behind, 8,12 and by the previous death of a child, 8,13 and weighed against the underlying desire for children and the need to avoid childlessness or cement a relationship. 6,8,10 An early study in pretreatment Rwanda, for example, described a marginal decline in pregnancies among HIV-positive women, shaped in part by health fears, but also by whether women had achieved a desired fertility norm. 14 As access to ART increased, several studies documented a rebound in fertility desires. 15,16 This included a 2005–2006 study of 501 HIV-positive women in Mbarara, Uganda (the same location as the current study), which found fertility desires positively associated with use of ART, and inverse to the World Health Organization (WHO) stage of illness. 15 In South Africa, Cooper et al. reported that HIV-positive patients (without access to care) felt that access to therapy for the prevention of mother-to-child transmission and ART would lead them to reconsider having children 13 ; in 2009 the same authors modeled these effects, reporting that use of ART restored fertility desires among HIV-positive women, but not HIV-positive men. 16 Rebounding fertility desires were subsequently borne out by a documented increase in the incidence of pregnancy after ART across multiple African countries. 17 Yet, even where ART is widely available, the lingering social consequences of endemic HIV can be significant, and may reduce the desire for children. A recent study comparing the fertility desires of HIV-positive to HIV-negative women in South Africa, in a context of widely available ART, reported significantly lower fertility aspirations among women with HIV-positive status, irrespective of ART use. 18 We theorized that the observed association in South Africa is shaped, in part, by individual and household legacies of the HIV/AIDS epidemic, such as the increased burden of caring for AIDS orphans 5 ; more female-headed households 19 ; increased rates of divorce, widowhood, and second marriages 12,19,20 ; HIV-related illness among family members 21,22 ; and the decline in household livelihoods. 23–25 Several of these factors are known to curtail fertility desires. 5,8,13,23,26,27 We undertook the present study in Uganda to examine the impact of women’s HIV status on their desire for future children, in a context of widely available ART, a sustained AIDS epidemic, and exceptionally high fertility norms (i.e., total fertility rate of 6.7 28 ), even for the continent of Africa. Uganda was among the first countries in Africa to experience a high and generalized HIV epidemic, with an estimated adult prevalence of more than 30% in the early 1990s. 29 The epidemic declined precipitously in the past decade, to an adult prevalence of 6.4% in 2009, 30 because of a combination of reduced incident infections, and high HIV-related mortality in the early years of the epidemic. 31,32 The context of widely available ART, a sustained AIDS epidemic, and high fertility norms enabled us to examine not only whether HIV status differentiates women in terms of fertility aspirations, but also whether such an association is explained, in part, by the social legacies of AIDS such as having an HIV-positive spouse, lower household income, widowhood or second marriage, the presence of foster children, or having an HIV-positive child in the household.
