标题：Childbearing Intentions of HIV-Positive Women of Reproductive Age in Soweto, South Africa: The Influence of Expanding Access to HAART in an HIV Hyperendemic Setting
摘要：Objectives. We investigated whether the intention to have children varied according to HIV status and use of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa. Methods. We used survey data from 674 women aged 18 to 44 years recruited from the Perinatal HIV Research Unit in Soweto (May through December 2007); 217 were HIV-positive HAART users (median duration of use = 31 months; interquartile range = 28, 33), 215 were HIV-positive and HAART–naive, and 242 were HIV negative. Logistic regression models examined associations between HIV status, HAART use, and intention to have children. Results. Overall, 44% of women reported intent to have children, with significant variation by HIV status: 31% of HAART users, 29% of HAART-naive women, and 68% of HIV-negative women ( P < .001). In adjusted models, HIV-positive women were nearly 60% less likely to report childbearing intentions compared with HIV-negative women (for HAART users, adjusted odds ratio [AOR] = 0.40; 95% confidence interval [CI] = 0.23, 0.69; for HAART-naive women, AOR = 0.35; 95% CI = 0.21, 0.60), with minimal differences according to use or duration of HAART. Conclusions. Integrated HIV, HAART, and reproductive health services must be provided to support the rights of all women to safely achieve their fertility goals. In sub-Saharan Africa, women of childbearing age comprise 61% of people living with HIV, accounting for over 12 million women. 1 In many regions, HIV incidence is increasing most dramatically among young women aged 18 to 30 years, 1 , 2 which coincides with their peak reproductive years. 3 Globally, a plethora of evidence indicates that many women living with HIV continue to desire children, 4 – 8 become pregnant, 5 , 6 , 9 and give birth 5 , 6 , 10 after knowing their HIV-positive status. Childbearing decision making can be complex regardless of HIV seropositivity 11 ; among HIV-infected women, however, reproduction introduces additional personal, public health, and clinical care issues. 12 The vast majority of conceptions occur without the use of reproductive technologies such as sperm washing and artificial insemination. 13 Thus, the unprotected sexual activity required for conception carries a risk of HIV transmission to uninfected sexual partners. 14 Reproduction among HIV-positive women also carries a risk of vertical transmission during pregnancy and labor and through breastfeeding. 15 , 16 Moreover, HIV-positive women have a lower life expectancy than HIV-negative women, 17 increasing the risk of maternal orphanhood. 18 In light of these concerns, early reproductive guidelines for people living with HIV were dissuasive, 19 and HIV-positive women who express a desire to have children continue to encounter the disapproval of the community and of health care workers. 4 , 20 Nonetheless, although the potential health risks may have dampened the fertility intentions of some HIV-positive women, stigma associated with childlessness in many societies 21 and the strong personal desires for biological parenthood 4 remain potent drivers of childbearing intentions, despite an HIV-positive status. Indeed, in some cultural contexts, remaining childless can be a violation of societal norms more stigmatizing than the HIV infection itself. 4 , 22 Expanding access to highly active antiretroviral therapy (HAART) is changing the landscape of childbearing decision making for people living with HIV. 23 HAART increases life expectancy, 24 – 26 decreases morbidity, 25 , 27 and dramatically reduces the risks of vertical 28 and horizontal 29 , 30 transmission. In this era of expanding access to HAART, the significant reduction in health risks and barriers to reproduction among people living with HIV has coincided with increased calls for a rights- and evidenced-based approach to reproduction. 31 , 32 Since childbearing intentions are among the strongest predictors of eventual childbearing, 33 creating effective and responsive sexual and reproductive health services for HIV-positive women in the context of expanding access to HAART requires a clear understanding of expressed childbearing intentions. Existing evidence concerning the influence of expanding access to HAART on childbearing intentions is largely incomplete. Although recent regional studies have shown that HAART use is associated with higher childbearing intentions, these studies neglected to consider the duration of HAART use 6 , 7 and tended only to compare the childbearing intentions of HIV-positive women without conducting a comparison with HIV-negative women from the same community. 6 – 8 Moreover, the lack of an HIV-negative control group precludes the opportunity to assess whether HAART users begin to resemble HIV-negative women in their childbearing intentions, particularly as HIV is increasingly recognized as a manageable chronic disease. Given the high HIV prevalence among women of reproductive age in Soweto, South Africa, 1 we aimed to assess the prevalence of childbearing intentions and to determine whether they varied according to HIV status and HAART use among women. We hypothesized that HIV-positive women would have lower childbearing intentions than would HIV-negative women. In addition, we hypothesized that HIV-positive women receiving HAART would have higher childbearing intentions than would HIV-positive HAART-naive women, with increasing duration of HAART treatment associated with incrementally higher childbearing intentions. Overall, we hypothesized that HAART use would narrow the measurable differences in childbearing intentions between HIV-positive and HIV-negative women. 23
