Background: The desire to give birth is the intention that both men and women will give birth to more offspring, despite being diagnosed with human immune virus. The desire of people living with HIV to have children can have major impact on public health. Despite the increasing importance of infertility problem in people living with HIV, little is known about their determinants.

Objectives: the aim of this study is to identify determinants of fertility desire among HIV positive reproductive age women who attend Anti-retro viral therapy clinic of public hospitals in north shewa, Amhara, Ethiopia, 2022.

Methods: Facility based unmatched case control study was conducted among 376(case=188, control=188) women in 4 selected hospitals in North shewa Zone. Finally, data was entered in to Epi Data version 4.6.0.0 and exported to SPSS version 20 for further analysis. Adjusted odds ratio with 95% Confidence interval was computed and P-value ≤ 0.05 was considered as statistically significant with fertility desire.

Results: A total of 188 cases and 188 controls completed the interview which made the response rate was 100% and the median age of the respondents were 35years (SD±6.9). Being married (AOR=3.5, 95%CI (1.72-6.94)), having fewer child (AOR=5.2, 95% CI (2.68-10.13)), awareness about Prevention mother to child transmission (AOR=7.9, 95%CI (3.41-18.22)) and currently not contraceptive use (AOR=3.1, 95% CI (1.74-5.70)) were independently associate with fertility desire.

Conclusion: Marital status, having fewer children, awareness about prevention mother to child transmission and current contraceptive use were significantly associated with fertility desire. Health care providers who are working on an Antiretroviral therapy clinic should try to discuss on sexual and reproductive health issues and provide proper counseling for those currently having fewer child, married couples and currently contraceptive use to have HIV free child with their clients.

Key words: Antiretroviral Treatment Clinic, Fertility Desire, Human Immune Deficiency Virus Positive Women,

The desire to give birth is the intention that both men and women will give birth to more offspring, despite being diagnosed with human immune virus, and the intention means a commitment to satisfy the desire [1, 2].

The desire to have a child is an expression of an HIV-infected person having a child in the future. One of the unexpected effects of antiretroviral therapy is that most people infected with human immune virus are of childbearing age, so one of the unexpected effects of ART could increase the desire of those affected by the disease to have children [3].

An estimated 36.7 million people worldwide live with HIV/AIDS. More than 25.5 million of them live in Africa, and 76% of all HIV-positive women live in sub-Saharan Africa [4].

Before the availability of antiretroviral therapy (ART) in Africa, women infected with HIV not only had reduced fertility, but also reduced fertility aspirations as many women, men, and health providers were opposed childbearing by persons infected with HIV. As access to ART increased, several studies documented a rebound increase in fertility desires [5, 6].

The desire of people living with HIV (PLWHA) to have children can have major impact on public health. Over 90% of HIV infections in infants worldwide are due to mother-to-child transmission (MTCT). Without proper intervention, HIV/AIDS infection rate ranges from 15% to 45%. This transmission rate can be reduced to less than 5% with effective interventions during the time of pregnancy, delivery, childbirth and lactation [7].

In Ethiopia, the prevalence of HIV was 1.8% for males and 2.8% for females. HIV prevalence among women of the reproductive age (15–49 years) was 0.9% and the most affected group are those who are sexually active and economically productive falling within the 25–49 age group [8].

Human immune virus and Acquired immune deficiency syndrome infection contributes to the decrease of fertility among PLHIV by causing abortion and stillbirth or through decreased sexual desire and marital disruptions among other ways [9, 10].

Despite the increasing importance of infertility problem in people living with HIV, little is known about their actual fertility needs and their determinant. It is important to help infected individuals who needs to have children and it serve as a benchmark for incorporating fertility-related counseling and services like PMTCT as appropriate, in to HIV treatment services [8]. The current study is designed to gain insight into the women’s fertility desire and its determinants.

Study Period and Area

The study was conducted from June 6 to July 24, 2022 in North Shewa, Ethiopia. North Shewa is situated 2,840m above sea level and 130 KM in Northeast of Addis Ababa.

A total of 3221 HIV-positive individuals were on ART follow-up at Debre Berhan ComprehensiveSpecializedHospital(DBCSH) ART clinic, of whom 1288 were females and 994 were women in the reproductive age, a total of 697 HIV positive individuals are on ART follow up at Enat General Hospital(EGH) ART clinic, of which 430 are females and 343 are women in reproductive age, a total of 472 HIV-positive individuals are on ART follow up at Mehal Meda General Hospital (MGH)ART clinic, of which 306 are females and 242 are woman in reproductive age and a total of 297 HIV-positive individuals are on ART follow up at Ataye Primary Hospital(APH) ART clinic, of which 181 are females and 160 are women in reproductive age.

Study design

 Facility based unmatched case control study was employed.

Sample Size Determination

Sample size was calculated using Epi Info version 7 for unmatched case control study. By taking 95% confidence interval, 80% power, 48.5% proportion of control and 51.5% proportion of case for HIV positive women with current sexual partners, an odds ratio of 1.9(4). Using 1:1 case to control ratio.10% was added to the initial sample size to accommodate for none response rate, final sample size is 376(188 cases, 188 controls).

Sampling Technique

In North Shewa Zone there are 10 public hospitals; so, by using simple random sampling technique four public hospitals were selected, which are Debre Birhan comprehensive specialized hospital, Mehal Meda general hospital, Ataye primary hospital and Enat general hospital.

Hence, the total respondents of 108 cases and 108 control, 26case and 26 controls, 17 cases and 17 controls and 37 case and 37 controls in DBCSH, MGH, APH and EGH were selected proportionally respectively. The sample size of each Hospital was collected by proportional to sample size. The respondent from each hospital registered in registration book and Smart care were selected through simple random sampling technique.

Operational definitions

Sexually Active Women who had at least one sexual practice during the last six months before the interview were labeled as sexually active [11].

Reproductive age group is defined as a woman within age ranges between 15-49 years and had started ART.

Fertility Desire is defined as having a wish or interest with capability to be pregnant at least once or more than one time within a definite time period after getting HIV infection [4].

The outcome variable for the study (fertility desire) was measured by answers to the question: “Are you currently planning to have (more) children in the near future? “Women’s were free to respond “Yes”, “No”, or “Do not know”, the small proportion of women who respond “Do not know”(if 5%)were included in the “No” category(7). Finally positive (“Yes”) response to the above question was observed as fertility desire.

 Data Collection Procedures and Tools

The questionnaire was adapted by reviewing different literatures and some modification was done by considering the local situation and study area.

For the identification of cases and control Data base 2 and Smart care was used since all HIV positive reproductive age women were registered in registration book and smart care so, they were listed in their age. Participants were interviewed face-to-face by trained data collectors using semi structured pre-tested questionnaires.

Data was collected by trained nurse and clinical pharmacist that were worked at ART clinic each hospital.

Training was given for 9 data collectors’ nurses and pharmacy. The questionnaire constitutes information on socio-demographic, socio-economic variables and HIV pregnancy-related knowledge, reproductive health related characteristics, clinical characteristics of participants and fertility desire related characteristics. Medical records of HIVpositive women were reviewed to confirm HIV status and other relevant medical history, including date of HIV diagnosis, recent CD4 count, ART status, date of ART start.

Data quality control

The questionnaires were designed carefully. A designed questionnaire was translated first in to Amharic and back to English to assure it consistency.

The questionnaire was pretested 5% of total sample size in Debre Sina Primary Hospital and the necessary modification was accommodated. The collected data was checked for completeness, accuracy, clarity, and consistency by supervisor and the principal investigators on daily basis. Any error or ambiguity and incompleteness were corrected. The patients’ response was checked with medical records and in case of inconsistent finding, patients’ response was taken.

 Data processing and analysis

Following accomplishment of data collection activities, the data was entered to Epi Data version 4.6.0.0 and then, exported to SPSS version 20 for further analysis. Descriptive statistic was done to summarize data and the result was reported using frequency and percentage. Then bi-variable logistic regression analysis was carried out to see the association between predictor variable and fertility desire. Variables which had p-value ≤ 0.25 were candidate for multi-variable logistic regression analysis to see the potential confounding variables. Multi collinearity test was done using variance inflation factor (VIF), which were <10 for each variable interaction.

Moreover, before using the model for further interpretation, the model adequacy was checked using Hosmer Lemenshow goodness of the fit statistical method, p-value >0.05.

Finally, variables with P-value, ≤ 0.05 in the multivariable logistic regression model was taken as statistically significant and adjusted odds ratio along with its 95% confidence interval was considered to see the association.

 Ethical consideration

The ethical clearance letter was obtained from Institutional review board of Debre Berhan University, Asrat Woldeyes Health Science Campus. All aspect of basic ethical research principle is addressed, and so the study participants were selected based on the research requirement.

 To ensure confidential, the data taken from respondent was kept in confidentially.

Socio-demographic characteristics of participants

The study included a total of 376 (188 cases and 188 controls) with response rate of 100%. Ninety-nine (49.5%) cases and 101(50.5%) controls among the respondents were urban residents. The median age of the respondents was 35 years old (SD±6.9). Among the respondents, 119(61.3%) of cases and 75(38.7%) of controls were married. Regarding educational status, 28 cases (36.4%) and 49 controls (63.6%) were illiterate (Table 1).

NB: other*(Muslim, catholic and protestant), other*b (unemployed, student, house servant and sex worker), other*** (Oromo, Guarage and Tigray)

Table 1:- Socio-demographic characteristics of cases and controls among HIV positive in the selected public hospitals of North Shewa Zone, Amhara region, Ethiopia 2022

Sexual and Reproductive characteristics

One hundred twenty-one (53.3%) of cases and 106(46.7%) of controls knew the status of their partner. Approximately two-thirds of 112(54.4%) of cases and 94 (45.6%) of controls were positive for the result of their partner.

Twenty-eight (23.9%) of cases and 89(76.1%) of controls had two or more children given birth in the past. Sixteen (76.2%) of cases and five (23.8%) of controls had no children at the moment. One hundred twenty eight (48.1%) of cases and 138(51.9%) of controls had undergone their first pregnancy at the age of 25 or older.

One hundred fifty-seven (47.7%) of cases and 172 (52.3%) of controls had been pregnant in the past. One hundred five (54.7%) cases and 87(45.3%) controls were pregnant after they had known their HIV status (Table 2).

This study aimed to identify determinant of fertility desire among HIV positive women who attend ART clinic of selected public hospitals in north shewa, Ethiopia from June 6 to July 24, 2022.

Marital status, current child, awareness PMTCT and current contraceptive use were found to be determinant of fertility desire.

The odds of being married were 3.5 times more likely to have fertility desire than mothers who were divorced. This study is consistence with facility base case control study conducted in Afar [6] which revealed that, the odd of being married were 5.5 times more likely to have fertility desire than the women who were un married and facility based cross sectional study conducted in AmhararegionalReferralHospitals[12], Hosannatown[13],Fitche Hospital[14],Uganda[15], which revealed that women who were married had higher odds to fertility desire than women who were divorced. This might be due to factor that better opportunity to discuss fertility related issue among couples and participants believe that the women with HIV positive can gave birth HIV free child and they want replace themselves and the women might get support from her husband at any time.

Being married created sense of security and reliable support to raise children. In Ethiopian society having children is highly valued and getting respectable in the society. In contrast, cross sectional study conducted in Addis Ababa show that being single women positive associated with fertility desire [16].This might be due to socio demographic difference, difference in study design, study period and sampling size.

Women who have fewer children 5 times higher odds to have fertility desire than women who had two or more children.

This finding is in line with cross sectional study conducted in Awi zone [12], Addis Ababa[16], Felege Hiwot Referral Hospital[17], South Africa (Cape town)[18], Uganda[19],which shown that women who had fewer child higher odds to have fertility desire as compared to women who had three or more children. This might be due to those who did not have a child need to replace themselves and as in the culture of developing; they need someone to taker of them when they become old age and weak. Those who had no children had strong desire for parenthood and desire children to achieve their social status by being a father or a mother.

Women who had awareness on PMTCT were 8 times higher odds to have fertility desire than women who did not have awareness on PMTCT to want to have a child. This study is in accord with a cross sectional study done in Hosanna town [13], which shown that women who had awareness on PMTCT had higher odds to have fertility desire than women who had not. This might be due to those who had awareness on PMTCT had service counseling when receiving follow up to reduce the likely hood of transmission to the new born and having good information by their health care giver.

Regarding contraceptive used, the odds fertility desire among women, who had not used contraceptive were three times higher compared to those who were used contraceptive. This study is consistent with a facility based case control study conducted in Jimma University Medical Center[4],which revealed that , the odd of fertility desire among the women who had not used family planning were two times higher as compared to those women living with HIV who had used family planning and cross sectional study conducted in Hosanna town[13] and Northern Nigeria[20], which revealed that women who had no used contraceptive higher odds to have fertility desire than those who used. This might be due to the fact that they have not attained their desired family size and unmet need of family planning service. The fact that contraceptive use is significant for HIV positive clients to space and limit births. In contrast, cross sectional study conducted in Finoteselam [21] showed that having not used contraceptive negatively associated with fertility desire. The possible reason for discrepancy might be due to poor economic status having less fertility desire.

This study revealed that married women, having fewer children, awareness about Prevention mother to child transmission (PMTCT) and currently not using contraceptive were the independent determinants of fertility desire among HIV positive reproductive age women who attend ART clinic of public hospitals in North Shewa, Amhara Region, Ethiopia, 2022.

As this study has identified different determinant factors of fertility desire, the problem may be alleviated by integrated collaboration of different stake holders.

For health care professional, who work with HIV positive women in HIV care and treatment units, can play a crucial role to provide accurate, nonjudgmental reproductive health information and appropriate counseling that includes safer sex practices and methods to decrease the risk of HIV transmission. For researcher further study including men and qualitative methods can help deepen understanding fertility desire among women living with HIV on ART follow up.

Consent for Publication: not applicable.

• Availability of Data and Material: the datasets during and/or analyzed during the current study is available from the corresponding author on reasonable request.

• Financial Disclosure: Wollo University was funded the research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

• Competing interest: The authors declare that they have no competing interest.

• Author’s contribution

BZ: Consult the research proposal, conducted the research, and analysis and wrote the manuscript.

 KD: Involved in the write up of the methodology of proposal, did data entry and research work.

We would likely to thank Debre berhan University, Asrat woldyes of health science campaus for giving this opportunity and support to conduct this research. Last but not least our appreciation goes to reproductive age women study participants.

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