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ART follow-up evaluation of reproductive choice among people living with HIV / AIDS in northwestern Ethiopia

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  • Save Public Health Research 2013, 3(2): 24-32 DOI: 10.5923/j.phr.20130302.03 Assessment of the Reproductive Choice of People’s Living with HIV/AIDS on ART Follow-up, East Gojjam, Northwest Ethiopia Amanuel Alemu, Gtachew Hailu*, Muluken Teshome Public health Department, Debremarkos University, Debremarkos, Ethiopia Abstract Ethiopia is currently one of the countries most seriously affected by HIV/AIDS with HIV prevalence of 4.7 % in 2005. Despite the growing importance of fertility issues for HIV-infected men and wo men, little is known about their actual fert ility intentions and family p lanning utilization. The objective of this study was to assess the fertility intention and family planning utilizat ion of people liv ing with HIV/AIDS who were onART follow up in East Go jjam. A cross-sectional institution based quantitative study supported by a qualitative study design was conducted from August 28/ 2009 to January 30/ 2010. A total of 360 PLW HAs and 12 key in formants were included in the quantitative&in the qualitative study design respectively. Data entry and analysis were made using EPI-In fo and SPSS version-16 soft wares. A univariat, b ivariate and mu ltivariate analysis was made using proportions, odds ratio and logistic regression. About 41.7% of the PLWHAs had a fertility intention with a contraceptive prevalence rate of 53.%. Those single and divorced PLWHAs utilized the family planning service 0.759 and 0.732 times less likely than the married PLW HAs[Adj.OR=0.241, 95% CI=0.061-0.955] and[Adj.OR=0.268, 95% CI=0.079-0.909], respectively. Moreover, those illiterate PLWHAs utilized the service 0.916 times less likely than who co mp leted grade twelve[Adj.OR=0.084 95% CI=0.013-0.557]. Those who did not disclose their serostatus to their service provider utilized the service 0.927 times less likely than who disclosed their condition [Adj.OR=0.073, 95% CI=0.020-0.0262]. The Un met need of family planning service among PLWAHS was found to be 34.2%. Most ART attendant PLWHAs had high fertility intention and more than half of them used family planning service but with high dropout of the service. Marital status, educational status and serostatus disclosure were found to be independent factors for family p lanning utilization. Keywords Fert ility Intention, PLWHAS, A RT, VCT, Family Planning Ut ilization 1. Introduction Since the onset of HIV/AIDS all region of the world had experienced the pandemic. Globally today a total o f 40.3 mil lio n p eop le are liv ing with HIV and 700,000 n ew in fect ions occurred in ch ild ren in 2005[1]. Sub-Saharan Africa has just over 10% of the world’s population, but is home to more than 60% of all people liv ing with HIV (25.8 million). In 2005, an estimated 3.2 million people in the region became newly in fected, while 2.4 million adults and children died of AIDS. A mong young people aged 15–24 years, an estimated 4.6% of wo men and 1.7% of men were liv ing with HIV in 2005. Considering regional variations, it has been found that Sub Saharan Africa remains by far the worst affected reg ion hit by the HIV/AIDS epidemic. This means it has had a heavy toll of human life and adversely * Corresponding author: Hailu) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved affects many activit ies in the world[2],[3]. Ethiopia is currently one of the countries most seriously affected by HIV/AIDS with HIV prevalence of 4.7 % in 2005. Heterosexual HIV t ransmission is responsible for most infection in Ethiopia and mother to child transmission also accounts the second and 30,000 HIV positive births occur in a year[3- 5]. 1.1. Fertility Intenti on of People Li ving with HIV As more than 80% of all wo men living with HIV and their partners are in their reproductive years, man will continue to want children after learning their positive status, whether to start a family or to have more children. Others may wish to regulate their fert ility, so that they can decide whether to try for a pregnancy and when. Fertility-related needs of wo men and men liv ing with HIV and of discordant couples may differ substantially fro m those who are HIV negative. HIV infection may affect sexuality because of fear of infecting the sexual partner(s), feelings of guilt and shame aggravated by stigma re lated to HIV, or e motional or psychological distress, reducing desire for or interest in sexual relations. With the Public Health Research 2013, 3(2): 24-32 25 increasing availability of antiretroviral t reatment and improvement in health status, there may be a renewed interest in sexual re lations and the desire to have children for wo men and men living with HIV. When it comes to family planning choices, when only one partner is HIV positive, the potential risk of transmitting HIV to the uninfected partner as well as the possibility of infection with other STIs should be taken into account. In addition, when both partners are living with HIV, possible re-infection with HIV has to be considered, although there is still uncertainty regarding the risk and consequences of re-infection.These issues may be perceived differently depending on factors such as living in a resource-poor country with limited access to both antiretrovira l therapy and STI[6]. The desire for children was found that about 13 % of respondents did want to have a child in spite of the regular counselling. The main reasons for not desiring to have children by HIV positives fro m qualitative study include we both are having a hard time because of infection then why to invite an innocent for suffering.A mong those respondents who were having children, 11 % of them had HIV positive children. And it was observed that 13 % of the respondents had their last child after diagnosis. Women who desired children were mo re likely either to be married or to have a partner (84%) than those who did not (64%). Men who desired children were no more likely to have had an opposite sex partner than were men who did not desire children. The percentage of men who identified themselves as bisexual was somewhat greater among those who desired mo re children (23%) than among those who did not (18%). Women who desired ch ildren were mo re likely to have a partner of unknown HIV status (32%) than were wo men who did not desire children (14%). A mong HIV-positive men and wo men who desired children, the percentage of those younger than 40 who actually expected to have children was almost always greater than the percentage that did not[7]. Nearlyhalf of HIV-positive wo men and 38 % of HIV-positive men expressed the desire for children. Another study conducted in the Un ited States concluded that overall, 28-29 % o f HIV-in fected men and wo men receiv ing medical care desire children in the future. A mong those desiring children, 69% of wo men and 59 % of men actually expect to have one or more ch ildren in the future. Further, it was observed in mult ivariate analyses that HIV-positive wo men who already had children were significantly less likely than others both to desire and to expect more births, partner's HIV status has mixed effects. Women whose partner's HIV status was known were significantly less likely to desire children but were significantly more likely to expect ch ildren in the future than arewomen whose partner's HIV status was unknown[10],[11]. About 20% of HIV-positive wo men aged between 20 and 40 and 22% of HIV positive men aged between 20 and 50 reported a current desire for children during the study period. An even larger proportion (47.5%) of HIV-positive wo men stated they would like to have children in the future. Individuals who experienced imp roved health while on HAART were significantly more likely to exp ress a desire for parenthood, while CD4+ count had no effect on the desire for ch ild ren. A mong HIV-d iscordant partnerships, inconsist ent condom use was independent of the currentdesire to conceive 22% withstrong vs. 32% with no fert ilitydesire (11). the desire for children among HIV-positive wo men age 15-49 to be 37.8% for those last tested in the past 12 months and learned their status; 32.5% for those last tested prior to the past 12 months and learned their status; and 39.4% for those who have never learned their status. Furthermore, a sizable proportion of infected wo men (38.7%) intend to have a child. Wo men who learn that they are HIV-infected may have a strong desire to avoid bearing additional children who may be born HIV-infected and will beco me orphaned at an early age[12]. About 40.2 % Persons living with HIV/AIDS desire for children. And the age group 18-29, being female, married/in relationship, having secondary education and above, having no children or 1-2 ch ild ren and partner desire for fert ility were identified as having association with desire for ch ild. On the other hand disclosure of sero status to partner/spouse has association with lo wer desire for children[13]. 1.2. Family Planning Utilizati on Status In Africa current level of contraceptive use is as low as they are already preventing 22% of HIV positive births. Here unintended pregnancy is high and its major cause is limited access to family planning with un met need of 36% in some countries with high prevalence[14]. Somestudies have pointed out that in the absence of HIV-related symptoms, the impact of having HIV on people’s decisions regarding childbearing and contraceptive use is generally weak[4]. HIV is the cause for the increase in demand as couples seek contraception to limit ch ildbearing, avoid pregnancy, avoid infect ion, or possibly gain weight if they have lost weight fro m HIV[15]. HIV-infected persons need to know that, aside from abstinence, condoms offer the best protection against STIs. Male or female condoms should be used every time intercourse occurs. There is concern that sexual partners of HIV-positive wo men using more effective contraception may not use condoms as consistently as partners of women using less effective contraception[7],[11]. Reasons of not using condom while doing s ex with s pouse were to bear child and lack of awa reness about transmission. Recent data fro m people accessing services for antiretroviral treatment and PMTCT in Ghana, Ethiopia, Kenya, Rwanda and South Africa shows that male condom are the contraceptive methods most frequently used however it is lower when the degree of intimacy increases[6],[7]. HIV positive Women with Knowledge of MTCT had higher unmet need, the opposite of the finding for HIV negative women. The un met need was lower among wo men who have spoken to family staff, irrespective of HIV status[12]. In Addis Ababa about 48.9 % and 33.7 % are ever user of contraception before and after the diagnosis 26 Amanuel Alemu et al.: Assessment of the Reproductive Choice of People’s Living with HIV/AIDS on ART Follow-up, East Gojjam, Northwest Ethiopia respectively. Fro m the methods they use abstinence 33.7% and condom 61 % are more p ractical[13]. 1.3. Significance of the Study Despite the growing importance of fertility issues for HIV-infected men and wo men, little is known about their actual fert ility intention and family p lanning utilizat ion[10]. Therefore, the study had tried to investigate the effect of HIV on fertility especially desire for ch ild ren and had given emp irical evidences of intention of fertility and contraceptive use among HIV infected people. Furthermore, the study would help in providing information that is helpful in programming and imp lementing PMTCT programmes. 2. Methodology 2.1. Study Design A cross sectional institution based study design was emp loyed. It was supplemented by qualitative in depth interview among people living with HIV/AIDS. 2.2. Study Area The study was conducted in East Gojjam Zone which is one of the eleven zones in Amhara Regional State of Ethiopia. There are 18 districts and 425 kebeles in the Zone. The total population resid ing in the Zone is 2,521,299 among this 282,248(11.2%) reside in the urban and the rest in the rural. One Zonal hospital and one district hospital, 18 functional health centres, 384 health posts and other upgrading health centres, 44 junior, mediu m and higher clin ics and 5 Govern mental organizat ional clinics are found in the Zone. The potential health service coverage in the zone is 94% A RT service was launched only at Debre Markos hospital and Motta hospital in 1998 and in 2000 E.C. it is started in five health centres name ly Debre Markos, Bichena, Dejen, Kuy and Merto Lemariam health centres (16). 2.3. Source Popul ati on All population on ART follow up care in health fac ility of the Zone is the source populations. 2.4. Study Population The study population was all PLWHA with at least one visit during the study period in the selected health facility. 2.5. Inclusion and Exclusion Criteria 2.5.1. Inclusion Criteria Women who were in the reproductive age group and men who were on ART follow up. 2.5.2. Exclusion Criteria PLWHAs those were seriously ill, unable to speak and hear. 2.6. Sample Size Determinati on 2.6.1. Quantitative Method The sample size was calcu lated using proportion of 40.2 % fertility intention wh ich was obtained fro m a study in Addis Ababa (11) and 14.7 % contraception prevalence rate (DHS 2005). The p roportion used is 40.2 % to get the maximu m sample size at 5% marg inal erro r with 95% confidence. Then using these assumptions the sample size was calculated by applying the formula of single population proportion. i.e. n= (zα/2)2 p (1-p) d2= (1.96)2 ×0.41×0.59 (0.05)2= 366 n = the required sample size P = assumed proportion of fertility intention Z= standard score corresponding to 95% confidence interval d = allowab le marginal error 2.6.2. Qualitative Method: Purposely selected twelve key informants that were not included in the quantitative part had part icipated in the study. 2.7. Sampling Procedure 2.7.1. Quantitative Method Samples were proportionately allocated according to the total number of PLW HAs who were at ART fo llo w up in each health facility. The selection was made fro m all health facilit ies in the zone that were giving ART service excluding Debre Markos HC in wh ich pre-test was done. The study subjects were interviewed at exit point until we get the required samp le size. 2.7.2. Qualitative Method Purposely selected twelve key informants: Two A RT service providers, Four PLW HAs association coordinators who were at ART follow up, Six PLWHAs who were on ART follow up that were not included in the quantitative part were included in the qualitative study. 2.8. Data Collection Instrument A structured questionnaire was used to collect the data. The questionnaire was prepared in English then translated to Amharic and again back to English. The questionnaire had contained questions that would request the informat ion about socio- demography, period of follow up, fertility intention, reasons for fertility intention, preparedness to prevent mother to child transmission and their family planning utilizat ion. A semi-structured questionnaire guide was used for the qualitative part. 2.9. Data Collection The data was collected starting from September 01, 2009 to September 22, 2009. The questionnaire was filled by the nurses who were working at ART clinics. Three days Public Health Research 2013, 3(2): 24-32 27 training was given to the data collectors and supervisors about confidentiality, responders’ right, informed consent, objective of the study, on techniques of the interview and how to fill the questionnaire. One supervisor who has at least first degree was assigned to each health facility and had supervised the data collection throughout the process. 2.10. Data Quality Control The data quality was assured by close follow up done by supervisors and principal investigators. The questionnaire was also checked for its co mpleteness and errors were corrected accordingly. The structured questionnaire was pre-tested on selected ART treat ment sites on a total of 37 subjects which is 10% of the samp le size. During pre-testing the questionnaire was checked for its clarity, simplicity, understand ability and coherency. Co rrection was made based on the feedback. For confusing words and phrases the local known wo rd by the consent of the respondent was used. 2.11. Data Analysis Procedures The data errors related to inconsistency were checked and corrected during data cleaning. The univariat analyses (proportions, percentages, ratios), bivariate analyses (odds ratio, chi-square) and logistic regression were used to display the findings of the study. The analyses was done using SPSS version 16.0.The strength of association was measured by 95% confidence interval and P value of 0.05 was used as a cut of point. 2.12. Ethical Consideration Ethical clearance letter was obtained fro m Eth ical clearance committee of Debre Markos University. Written consent was obtained from East Gojjam Zonal health department and from the respective health facilit ies. All the study participants were informed about the purpose of the study and finally their consent was obtained before interview. The informat ion provided by each respondent was kept confidential. The dissemination of the finding did not refer specific respondent. 3. Results 3.1. Socio-Demographic Characteristics of the PLWHAs Among 366 PLWHAs included in the study, data was obtained from 360. This makes the response rate to be 98.36%. The mean age of the respondent was 33.3±7.3 with a variance of 53.289. About 59.2% of the respondents were females. Most (87.5%) of them were orthodox in relig ion. The majority (41.1%) of the respondents were with educational status of read and write only. Nearly all (98.9%) of the respondents were Amhara in ethnicity. Most (45%) of them were married and only 11.11% were single (Tab le-1). Table 1. Socio-demographic characteristics of PLWHAs, East Gojjam Zone, Amhara Regional State, Ethiopia 2010 Variable Age 16-25 26-35 36-44 45-49 Sex Male Female Educational Status Completed & above Read & write only Illit erat e Other Distance from the nearest Health institution ≤10km >10km Monthly Income ≤500 501-1000 1001-1500 ≥1501 Frequency 52 142 136 30 147 213 90 148 119 3 184 176 295 35 23 7 Percent (%) 14.40 39.40 37.80 8.30 40.80 59.20 25.00 41.10 33.10 0.80 51.10 48.90 81.90 9.70 6.40 1.90 3.2. Fertility Intenti on ofthe PLWHAs About 41.7% of the respondents (PLWHA) intended to give birth in the future. The majority (58.3%) have no fertility intention in the future. More than one-fifth (21.9%, n=79) of them had never gave birth yet. Currently, 26.9% have one child and 49.4% have more than one child. About 12.8% (n=46) of the respondents gave birth after they know their serostatus (Table-2, fig -1). Fro m the qualitative part of the study, we found that most of the interviewee (participants) had the intention to have a child. We have quoted some statements as follows: Table 2. Fertility Intention of the PLWHAs, East Gojjam Zone, Amhara Regional State, Ethiopia 2010 Fertility intention Gave birth Yes No Gave birth after serost at us check-up Yes No Other Last pregnancy was wanted Yes No Other Currently pregnant Yes No I do not know Have an intention to give birth Yes No Frequency 281 79 Percent (%) 78.10 21.90 46 16.37 231 82.21 4 1.42 201 71.53 37 13.17 43 15.30 16 5.10 293 94.20 2 0.70 150 41.70 210 58.30 28 Amanuel Alemu et al.: Assessment of the Reproductive Choice of People’s Living with HIV/AIDS on ART Follow-up, East Gojjam, Northwest Ethiopia 60.00% 50.00% 53.30% 40.00% 28.70% 30.00% 20.00% 10.00% 10% 8% 0.00% 1 2 3 4 Number of children Figure 1. Number of children PLWHAS intend to have, EGZ, ARS, Ethiopia, 2010 A 40 years old married male part icipant said, “Some of those living with the virus are giving birth for begging purpose due to their poor socio-economic status. They say let us eat and die.” A 35 years old divorced female who is 12th grade complete and a coordinator of one PLWHAs association said “Most of my friends including me planned to have a child if we can deliver a healthier baby; we have no problem to be pregnant except our poorness and health problem. I have only one alive female ch ild. I will be happy if I have a male child. I do not consider a single female child as alive because a single child is the same as no child.” She also said, “In my association, one female leady who lives with the virus was egger to have a child and went to DebreMarkos Hospital for cervical cancer screening before being pregnant but she had referred to Black Lion Hospital for treat ment, she was not cured for the disease, rather aggravated and had admitted for follow up. Then after when she thinks about a child, she cries .” A 37 years old widowed female who is 8th grade said, “I have three female children but I do not have any male ch ild. I want to have a male child but I am afraid of the child being infected by the virus.” A 32 years married female who is 10th grade said, “It is a baby that makes me funny. I joined OSSA and married a health professional man. We consulted health professionals that we want to have a child and we were to ld that we can have a child with PMTCT p rogram and our dream was successful with a hea lthier fe ma le baby.” A 27 single female who is 9th grade and a daily worker said, “Three men asked me for a wife but I have ignored all of them due to their mu lti-sexual behaviour. If I get the right husband, I will marry h im and want to give a b irth.” 3.3. PLWHAs Family Planning Utilization The majority (53.6%) of the respondents reported having used contraceptives, currently. About 45% of the respondents had utilized contraceptives before their serostatus check-up and 37.5% of them had used after their serostatus check-up. Most (42.6%) were using Depo-Provera method of contraceptive before they know their serostatus. However, about similar proportion (43%) of them is using abstinence, currently (Table-3). Table 3. P LWHAs Family planning ut ilizat ion, East Gojjam Zone, Amhara regional state, Ethiopia 2010 Fertility intention Use of contraceptive before serost at us check-up Yes No Fo rgott en No answer Method of contraceptive used before serostatus check-up Abst in ence Condom OCP Depo-Provera Implant Other Use of contraceptive after serostatus check-up Yes No No answer Partner/ self-utilization of contraceptive currently Yes No Method of contraceptive utilizing currently Abst in ence Condom OCP Depo-Provera Implant T ubal Ligation Frequency Percent (%) 162 45.00 186 51.70 3 0.80 9 2.50 15 9.30 13 8.00 53 32.70 69 42.60 5 3.10 7 4.30 135 37.50 191 53.10 34 9.40 193 53.60 167 46.40 83 43.00 57 29.50 4 2.10 37 19.20 7 3.60 5 2.60 3.4. Factors that Influence Family Pl anning Utilization of the PLWHAs Among those who utilize contraceptive currently, more than half(50.8%) of them use because of health professionals counselling. Whereas, 33.7%, 4.1% and the rest 11.4% of them use because it is co mfo rtable for their health, adoption of pears experience and other reasons, respectively. More than one-third (34.7%) of them d id not disclosed their condition to their family planning service provider. The majority (54.9%) of them, however, disclosed their condition for their service provider. Of those who did not disclose, most (33.2%) did it since they fear stigma and discrimination. The rest 30.1%, 13%, 16.6% and 7% not disclosed their condition because of no need of help fro m service provider, fear of confidentiality, unknown and other reasons, respectively.Among those who are not using contraceptive, currently, most (43.7%) do since they have no partner. Others, 13.8%, 8.4%, 4.8% and 21% do since they need to give birth, their partner disagree, fear of side effects and other reasons, respectively. Moreover, most (48.7%) do not need to use contraceptive in the future. However, about 34.2% need to use. Of which 59.90% need to start as soon as possible and the rest 7.8%, 4.8%, 4.8% and 22.8% within six Public Health Research 2013, 3(2): 24-32 29 month, within one year, after one year and within undecided time, respectively. A mong those who need to use contraceptive in the future, the majority (32.9%) need it not to give birth. The rest 28.7%, 9.6% and 28.7%, to spaced and limit their b irths and other reasons, respectively. Fro m the qualitati ve part, we found that most of the interviewee (part icipants) did not use any FP method before knowing their HIV status due to fear of the method but after confirmat ion for HIV/AIDs, most of them use at least one method. A 35 years old, PLW HA facilitator, married female who is 12+3 said, “Before knowing my status, I did not use any FP method except the natural method. One day due to my fear of asking pills in DMH, I went to Bichena Health centreand asked the nurse to give me pills but as she said due to yellowish discoloration of my eyes, she referred me back to DMH. Then after, t ill HIV/AIDs confirmation due to my fear of asking pills in DM H, I did not use any method but after knowing my HIV status, I am using condom.” A 32 years old married female and 10th grade participant said, “Before knowing my status, I d id not use any FP method due to fear of FP but after confirmation of HIV/AIDs, I abstained for 12 years then I have married and after having a child now I am using Depo-Provera because condom is not comfo rtable for me.” A 27 years old single fema le and 9th grade participant said, “Before knowing my status, I started to use pills and then stopped using it due to discomfort. I do not use condom because I heard that it will remain in the uterus after sexual intercourse and even after confirmat ion of HIV/AIDs, I am using Depo-Provera.” A 31 years old married male farmer who is illiterate participant said, “Before knowing our status, we do not use any FP method but after confirmation of HIV, we use condom for sexual intercourse because even if the name is virus my wife’s virus may differ fro m mine as our face is diffe rent.” 3.5. Mul ti variate Analysis PLWHAs Family planning utilization in relation to factors that was significantly associated at bivariate analysis. The mu ltivariate analysis indicated that educational status, marital status and disclosure of the serostatus were independent determinants of family planning utilization of PLWHAs. Those illiterate PLW HAs were 0.916 times less likely utilize family planning service than who co mpleted grade twelve[Adj.OR=0.084 95% CI=0.013-0.557]. Those single and divorced PLW HAs were 0.759 and 0.732 times less likely utilize the service than who were married [Adj.OR=0.241, 95% CI=0.061-0.955] and[Adj.OR=0.268, 95% CI=0.079-0.909] respectively. And those who did not disclose their serostatus to their service provider 0.927 times less likely utilize than who d isclosed their condition [Adj.OR=0.073, 95% CI=0.020-0.0262] (Table-4). Table 4. PLWHAs Family planning utilization in relation to some factors, East Gojjam Zone, Amhara, Regional State, Ethiopia 2002 E.C Fact ors FP utilization Yes n(%) Non(%) Adj.OR (95% CI) p-Value Educat ion al st at us CompletedRea d and writ eIllit erat e 59(65.60) 70(47.30) 63(52.90) 31(34.40 78(52.70 56(47.10 1 10.2(0.05-1.1 0.075 0.08(0.01-0.6) 0.010* Marital status Married Single WidowedDivo rced Occup at ion St uden tMerch ant Housewife Daily labourer Farmer Pro st it ut e Employed Aware PMT CT Yes No Disclosed Yes No 102(63) 13(32.50) 21(51.20) 57(48.70) 1(12.50)3 6(53.70)3 5(63.60)2 0(54.10)3 3(52.40)2 3(57.50)3 5(63.60) 139(57.2) 39(43.30) 99(93.40) 57(65.50) 60(37) 27(67.5) 20(48.8) 60(51.3) 7(87.50) 31(46.3) 20(36.4) 17(45.9) 30(47.6) 17(42.5) 20(36.4) 104(43.) 51(56.7) 7(6.60) 30(34.5) 1 10.24(0.1-0.9) 1.89(0.2-19.9) 0.27(0.1-0.91) 0.043* 0.596 0.035* 1 10.69(0.1-4.1) 1.70(0.28-10) 2.80(0.45-17.) 3.25(0.47-23.) 0.41(0.08-2.3) 1.91(0.22-17.) 0.683 0.560 0.268 0.234 0.306 0.557 1.00 0.49(0.05-5.2) 0.554 1.00 .07(0.02-0.03) <0.001* 4. Discussion 4.1. Socio Demographic Characteristics It was known that young, sexually active individuals are the most vulnerable groups of people for HIV in fection. Among the PLWHAs included in this study, 14.4% were within the age group of 16-25. Of which 82.7% were wo men and the rest were men. Th is finding in formed that the most affected and bitten group of the community were wo men. The study also disclosed that high proportion (41.1%) of the PLWHAs were with educational status of write and read only. Low level of education, then, might be considered as a contributing factor for acquiring the infection. In addition, low level of average monthly inco me tends to accompany high risk of acquiring the infection. In this particular study, most PLWHAs (81.9%) responded having an average monthly inco me of less than 500 ETB. In spite of the general expectation of the correlation between the high risk of HIV infection and lo w level o f income, the temporal sequence was hardly detected by this study. Low average monthly income might be due to positive serostatus or visversal. Therefore, the issue of tempora l sequence in terms of which one comes first must be, further investigated. Moreover, large proportion (45%) of the PLWHAs included in this study was married. This finding might contradict with the 30 Amanuel Alemu et al.: Assessment of the Reproductive Choice of People’s Living with HIV/AIDS on ART Follow-up, East Gojjam, Northwest Ethiopia general truth and perception of human being in that the married ones are expected to be at less risk for the infection than others are. The possible explanation fo r such contradiction might be the time o f infection might precede the time of ma rriage without serostatus check-up. This might increase the probability of infecting the partner thereby increase the proportion of infected married individuals. 4.2. FertilityIntention of the PLWHAs Among the PLWHAs who were included in this study, the huge proportion (78.1%) responded having gave birth. However, this study did not assess the proportion of PLWHAs, who had HIV positive children. About 16.37% of the respondents had their child after their diagnosis. This was in line with the study in Mumbai in which 13% had their child too (7) but higher than a study finding (7%) inSouth Wollo Zone, Northeast Ethiopia (18).It was found that men were mo re likely desire to have a child (47.6%) than wo men (37.6%). This was supported by a study conducted in Ethiopia which disclosed41.7% Male and 24.4% Fe malehave a desire to have children in the future (19). But it contradicts with the study finding in Nigeria that mo re female desire to have children than males (65.5% vs.61.2) (20). This may be due to the difference in the study setups. Despite living with the in fection, about 41.7% did want to have a child. Th is study finding was in line with the finding of a study in Addis Ababa, which found 40.2% persons liv ing with HIV/AIDS desire for a ch ild (13). A study in Mumbai, wh ich showed about 13% of the respondents, had having the desire for children in spite of the regular counselling (7) and a study in US which showed about 45% of HIV positive wo men and 38% of men had expressed the desire (10,11). Studies in Eth iopia and Guinea had found consistently increased desire for a child with 36.4%, 66.1% and 34%, respectively (18, 19, 22). Different reasons were cited fo r the desire of children. However, most cited the need to replace race as a reason for their desire. Others need to have a child since they need to make secret their serostatus, for the partner need or as a preventive mechanism of stig ma and discrimination. This might have an implication for re-infect ion and infection transmission to either the discordant partner or other individual due to d ifferent mode of trans mission of HIV, although it was discussed as there is still uncertainty regarding the risk and consequences of re-infect ion. It was found that among those who desire children 46% and 32% were in age group of 26-35 and 36-44 respectively. The huge proportion of PLWHAs with the desire for a child in the future falls in the adulthood age. 4.3. Family Planning Utilizati on In this study, it was found that most PLWHAs (53.3%) were using family planning service currently. This was due to the influence of med ical care providers who were advising and initiating them to use the service. This is in line with the study finding inUganda which disclosed 55.1% were using a family planning (contraception) method (21). It was also known that large proportion (45%) of the PLWHAs was using the service before having serostatus check-up compared to the proportion of PLWHAs utilizing the service after serostatus check-up (37.2%). Th is indicate that about 28.9% of the PLWHAs who were using the service either before or after serostatus check-up had dropped or interrupted using the service, currently. The possible explanation for such an interruption of using the service might be having the desire for children or fear of side effects of some of the contraceptives. PLWHAs were using Depo-Provera before and abstinence after they had serostatus check-up. This might indicate that how much the family planning service providers were at high risk for the infection. Since PLW HAs before having serostatus check-up were using Depo-Provera, those who provide the service without safety precautions would be exposed to the infection. The method used by PLWHAs after serostatus check-up (Abstinence) on the other hand help to reduce infection transmission or re-in fection because of reduced sexual contact. In this study, it was found that disclosing the serostatus for service provider was an important influential factor for family planning utilization. Those PLW HAs who disclosed their status were tending to use the service mo re likely compared to those who did not disclosed. Stigma and discrimination, fear of confidentiality and no need of help fro m service provider were mentioned as major influential factors to not disclosing the status. This might inform us that stigma and discrimination, issue of confidentiality and lack of awareness about the role of family planning service providers are still the area of concern for intervention. Having no partner was cited by most PLWHAs as a reason for not utilizing family planning service. Others cited a desire for children as major reason for not utilizing the service. The latter should be considered as a great issue with respect to both the re-infection and transmitt ing the infection. About 13.2% of the PLWHAs among those who gave birth mentioned that their last pregnancy was unwanted. This was because of the unmet need of the huge proportion of PLWHAs (34.2%) for family p lanning service. This finding was supported by the fact sheet series of population action international, wh ich found out a 36% of unmet need among PLWHAs (14). 4.4. Knowledge of the PLWHAS about PMTCT, VCT &ART and Practice of Condom Use Those PLWHAs who were aware of PMTCT tend to use family p lanning service (57.2%) more likely than those who did not (43.3%). It was also identified that PLWHAs with high CD4+ count and those who started ART before t wo years tend to use the service more like ly than those with low CD4+ and who started with in less than one-year do. This might contradict with the previous study finding about reproductive choice for wo men and men living with HIV, which showed renewed sexual relat ions and desire to have Public Health Research 2013, 3(2): 24-32 31 children(less likely utilize family p lanning service) as the health status is improved because of ART. This contradiction could be expla ined that the increased awareness of PLWHAs about PMTCT, because of frequent counselling for long duration brought increase use of the service in this particular s tud y . status, marital status and disclosure of serostatus for service provider were identified as independent determinants of family p lanning utilization. ACKNOWLEDGMENTS 4.5. Discussion on Bi variate and Multi variate Analysis Age and marital status of the PLWHAs were found to be statistically significantly associated with desire for children at bivariate analysis. Those elder PLWHAs (45-49 years old) tend to desire for a ch ild 0.696 times less likely co mpared to those younger ones (16-25 years o ld). The p lausible explanation for this could be those elder PLWHAs might more likely have children before or after diagnosis than youngsters and might not need more ch ildren. Young PLWHAs on the other hand less likely have a child and consequently have a desire for children. Those widowed and divorced PLWHAs had 0.554 and 0.462 times a reduced desire for children than the married ones respectively, but the single PLWHAs were 1.19 times more likely have the desire for ch ildren than the married ones. This might be due to the psychological disturbance of the widowed and divorced ones, which might affect their desire on one hand or might already have children that reduces the desire for additional children or might be due to cultural taboos that hinder them to have a partner. The single PLW HAs’ high desire to have a child might be due to lack of children as a result of being within young age group. In this study aware of PMTCT and occupation of PLWHAs, wh ich were significantly associated with family planning utilization at b ivariate analysis, could not maintain their significant association at multivariate analysis. This could be because it might be confounded by other factors at bivariate analysis. Therefore, occupation of PLWHAs and awareness of PMTCT are not determinants of service utilizat ion. Educational status, marital status and disclosure of serostatus were found to be independent determinants of family p lanning utilizat ion. Those illiterate PLWHAs were 0.916 times less likely utilize family planning service than those who were grade 12 co mpleted [ Adj.OR= 0.084, 95% CI= 0.013-0.557 with P= 0.010 ]. This might be due to less awareness of the service and PMTC Our sincere and deepest gratitude goes to the East Gojjam Zone HAPCO in supporting us with financial perspectives. Our gratitude also goes to the Public Health Faculty staffs who support us in supervision and monitoring of the data collection process and who give us a technical assistance for the successfulness of this study. We are also grateful to the DMU finance and higher officials for facilitating our activities. Our special thank also goes to the data collectors (nurses working at ART clin ics) for their ad mirable endeavor. At last but not least our sincere gratitude goes to the East Go jjam health sectors and the community who provide us constructive information for the study to be effective. REFERENCES [1] WHO, USAID. AIDS Epidemic update: Especial report on HIV Prevention. WHO, USAID; 2005. [2] WHO. HIV/AIDS Epidemiological Surveillance for African region 2005 Update. Zimbabwe: 2005. [3] Disease prevention and control department. AIDS in Ethiopia 6th ed. M OH; Addis Ababa, Ethiopia: 2005. [4] HAPCO. Report on progress towards implementation of the Declaration of Commitment on HIV/AIDS. Federal Democratic republic of Ethiopia; Ethiopia: 2006. [5] Central Statistical Authority (CSA) and ORC M acro. Ethiopian Demographic & Health Survey. CSA & ORC M acro; Addis Ababa, Ethiopia: 2005. [6] The Reproductive choice for women and men livingwith HIV. (Reproductive Health M atters 2007; vol 15). p. 46-66. [7] Ranjan S. Fertility and Desire for Children among HIV infected persons with especial reference to M umbai. [8] Elizabeth A, Ellen G. prevention of mother to child transmission of HIV in Africa: Practical Guid line for programmes .SARA, USAID; 2001. 5. Conclusions It was found that PLWHAs have a high desire for child ren (41.7%). Youngsters were both with high desire to have children and at high risk of acquiring the infection. Women were with low desire for children but were the most affected groups by the infection. PLWHAs with high average monthly inco me had high intention for fertility. More than half of the PLWHAs were utilizing family planning service currently. Moreover, more than one-fourth interrupted service utilizat ion and nearly one-six had unwanted pregnancy with unmet need of about 34.2%. Educational [9] Engender health preventing HIV/AIDS through Family planning in gender Health improving women’s Health worldwide. [10] Chen J, Kanouse D, Cllins R and M aul A. Fertility desire and intention of HIV Positive men and Women. (Family planning perspective 2001; vol 33).P. 144-152&165. [11] Laure P, M annual B, Andre F et al. High Risk sexual behaviour and two Challenging issue. SWISS M ED WKLY; 2003. (vol 133). P. 124-127. [12] Tim A. Desire for children and unmet need for Contraception among HIV positive Women. DHS working paper. Lesotho: 2007. (Demography and Health Research; vol2 ). 32 Amanuel Alemu et al.: Assessment of the Reproductive Choice of People’s Living with HIV/AIDS on ART Follow-up, East Gojjam, Northwest Ethiopia [13] Temam W. Fertility desire and Family planning demand among HIV positive men and women in ART follow up care in Addis Ababa. M aster thesis Addis Ababa University; Addis Ababa, Ethiopia: 2006. [19] B. Alemayehu and A. Aregay. Desire to procreate among people living with HIV/AIDS: Determinants in Ethiopia: A cross-sectional study. Journal of AIDS and HIV Research Vol. 4(5), pp. 128-135, M ay 2012. [14] Population action International. Family planning: crucial information for HIV Positive Women, Fact sheet; 35 series. [15] UNAIDS, WHO, AIDS Epidemic update special report on HIV.WHO, UNAIDS; Geneva: 2005. [16] FHI, USAID. Family planning needs in the context of HIV/ AIDS epidemic: country assessment. Zimbabwe: 2004. [17] East Gojjam Health department.Annual report 2000 E.C. [18] M enberu G, Fessehaye A, M ulumebet A, Amare D. Factors affecting fertility decisions of married men and women living with HIV in SouthWollo Zone, Northeast Ethiopia. Ethiop. J. Health Dev.2010; 24(3):214-220. [20] Iliyasu Z, Abubakar IS, Kabir M , Babashani M , Shuaib F, Aliyu MH. Correlates of fertility intentions among HIV/AIDS patients in northern Nigeria. Afr J Reprod Health. 2009 Sep;13(3):71-83. [21] Othman Kakaire1, Dan K. Kaye1* and M ichael O. Osinde2. Contraception among persons living HIV with infection attending an HIV care and support centre in Kabale, U ganda. Journal of Public Health and Epidemiology Vol. 2 (8), pp. 180-188, November 2010. [22] M arie Lucy Aska, JirapornChompikul*, Boonyong Keiwkarnka. Determinants of Fertility Desires among HIV Positive Women Livingin the Western Highlands Province of Papua New Guinea. World Journal of AIDS, 2011, 1, 198-207.

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