Knowledge on mother-to-child transmission of HIV, and sexuality and fertility desires among people living with HIV in North-Central, Nigeria
Chikwendu Amaike, Tolulope Olumide Afolaranmi, Blessing Adaku Amaike, Hadiza Agbo, Olumide Abiodun
Corresponding author: Chikwendu Amaike, Department of Community Medicine, College of Health and Medical Sciences, Babcock University, Ilishan Remo, Ogun State, Nigeria
Received: 31 Aug 2021 - Accepted: 13 Sep 2021 - Published: 28 Sep 2021
Domain: Infectious diseases epidemiology,Community health,Maternal and child health
Keywords: Mother-to-child transmission, sexuality, fertility, Nigeria, HIV, reproductive health services, anti-retroviral treatment
©Chikwendu Amaike et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this article: Chikwendu Amaike et al. Knowledge on mother-to-child transmission of HIV, and sexuality and fertility desires among people living with HIV in North-Central, Nigeria. Pan African Medical Journal. 2021;40:64. [doi: 10.11604/pamj.2021.40.64.31455]
Available online at: https://www.panafrican-med-journal.com/content/article/40/64/full
Knowledge on mother-to-child transmission of HIV, and sexuality and fertility desires among people living with HIV in North-Central, Nigeria
Knowledge on mother-to-child transmission of HIV, and sexuality and fertility desires among people living with HIV in North-Central, Nigeria
Chikwendu Amaike1,2,&, Tolulope Olumide Afolaranmi3, Blessing Adaku Amaike4, Hadiza Agbo3, Olumide Abiodun1
Introduction: mother-to-child transmission (MTCT) is the transmission of HIV from a mother to the child during pregnancy, labour and breastfeeding. People living with HIV (PLHIV) are sexually active and also HIV can be transmitted while trying to achieve pregnancy involving unprotected hetero-sexual intercourse. Fertility desire among PLHIV is increasing due to improved quality of life and survival following commencement of anti-retroviral treatment and available reproductive health services. The objective of the study was to determine the association between knowledge on MTCT of HIV and sexuality and fertility desire.
Methods: this study was descriptive cross-sectional applying systematic sampling technique among PLHIV using semi-structured interviewer administered questionnaires. Data was analysed using SPSS version 23.0. Chi square test was used for statistical analysis. At 95% confidence interval a P-value of <0.05 was considered to be statistically significant.
Results: a total of 168 PLHIV were studied, 63.3% females and 36.7% males. Majority (81.5%) of the respondents were sexually active and 64.1% had fertility desire. On awareness of MTCT 62.5% had heard of MTCT but only 28.2% had good knowledge. No association was found between knowledge of MTCT and sexuality and fertility desire respectively.
Conclusion: PLHIV had high awareness but poor knowledge on MTCT of HIV, hence the need for healthcare workers to provide sexual and reproductive health counselling including information on MTCT to both male and female PLHIV during routine clinic visits.
Human immune deficiency virus (HIV) infection remains a major global public health issue, with about 74.9 million people infected and more than 32 million deaths since the onset of the epidemics up to 2018 , and Nigeria having the second largest HIV epidemic in the world and one of the highest rates of new HIV infections in sub-Saharan Africa . The HIV infected mother can transmit the virus via both the horizontal and vertical routes. In the vertical route, a pregnant woman transmits HIV to her unborn child during pregnancy, delivery and breastfeeding. This is referred to as mother-to-child transmission (MTCT) [3,4]. Mother-to-child transmission of HIV, however, be effectively reduced or prevented if both mother and baby are placed on antiretrovirals (ARV). In the absence of ARVs, the rate of HIV infection from MTCT is between 15 to 45% . The comprehensive approach to prevention of mother-to-child transmission (PMTCT) programmes include prevention of new HIV infections among women of childbearing age, prevention of unintended pregnancies among women living with HIV, prevention of HIV transmission from a woman living with HIV to her baby and provision of appropriate treatment, care and support to mothers living with HIV, their children and families .
Nigeria accounts for about 30% of all cases of MTCT of HIV globally, but only about 40% of pregnant women in Nigeria living with HIV were on antiretroviral therapy (ART) for PMTCT in 2018 . PLHIV have a right to a satisfying, safe and healthy sexuality and reproductive health, but HIV can be transmitted in the attempt to achieve pregnancy involving unprotected hetero-sexual intercourse. Furthermore, fertility desire among persons living with HIV (PLHIV) is increasing due to improved quality of life and survival following commencement of ARV treatment and also the availability of reproductive health services. Knowledge on MTCT and the utilization of PMTCT services by men and women infected with HIV who are sexually active and have fertility desires may affect the risk of MTCT of HIV. However, little is known about the relationship between the knowledge of MTCT of HIV and the sexuality and fertility desires of PLHIV.
Study objectives: this study was aimed at assessing the sexuality, fertility desire and knowledge of MTCT and also to determine the relationship between the knowledge of MTCT and their sexuality and fertility desire.
Study design: it was a cross-sectional study on knowledge of the clients on MTCT and to relate their knowledge with their sexuality and fertility desire.
Study location: this research was done at the Seventh-day Adventist (SDA) Hospital, Jengre, in Bassa Local Government Area (LGA) of Plateau state, Northcentral Nigeria. The hospital is a 58-bed spaced; faith-based secondary health facility established in 1947 , which provides comprehensive HIV/AIDS care with support from the AIDS Prevention Initiative Nigeria (APIN) Public Health Initiative. Services provided include HIV testing and counselling services (HTS), ARV drugs, PMTCT, screening and treatment of other sexually transmitted infections (STIs), prophylaxis and treatment of opportunistic infections (OIs), post exposure prophylaxis (PEP), pre-exposure prophylaxis (PreP) and family planning commodities. Adults PLHIV who were on ART at the time of this study were 1,432 and 1,146 of them had been on ART for six months and above, a period of time expected for that viral suppression is expected to have occurred. The HIV programme is integrated into the routine daily out-patient care of the hospital. Patients visit the hospital at least twice a year to pick up their drugs, get clinical assessment and run laboratory tests. Bassa LGA is one of the 17 LGAs in Plateau State and it is located at the northern part of the state, with an area of 1,743 Km2 and a population of about 200,000 . Plateau state is the twelfth largest state in Nigeria with a population of about 3.5 million people with an area of 30,913km2 .
Study population: this study was conducted among clients who access care for HIV in SDA hospital.
Eligibility criteria: males and females 18 years and above who have been on ARVs for a period of six months and above prior to the study were included. Females who were not within the reproductive age group (15-49 years) were however, excluded from the study.
Study size: appropriate sample size formula was used to determine the minimum study size , where Zα is the value of alpha error at 95% confidence level given as 1.96, P is knowledge of MTCT of HIV found to be 50.3% in Tehran  and d is the precision which was set at 15% of 50.3%. A 5% possible non-response was considered and a minimum study size of 168 was gotten.
Selection of participants: systematic sampling technique was used to select the study participants. A sampling frame generated from the electronic data base of patients who access HIV care in the hospital showed a total of 1,146 eligible participate for this study. A sampling interval of 7 was gotten by dividing the number of eligible participants by the minimum study size. The first participant was then selected by simple random sampling technique by balloting between the first and second numbers on the sampling frame. The sampling interval of 7 was then applied to select the subsequent participants till the minimum study size was attained.
Variables: knowledge on MTCT is the explanatory variable while fertility desire and sexuality are outcome variables.
Collection of data: advocacy visits were paid to the administrative committee of SDA hospital and also the leaders of the support group of PLHIV for the hospital to brief them on the aim of the study and solicit their support in carrying out the study. One-day training was conducted for research assistants (two doctors and three nurses) who work in the hospital´s ART clinic for the purpose of administering the questionnaires. Questionnaire adapted from previous studies [11,12] was pre-tested among HIV clients in a comprehensive HIV care site in a border state. This was to correct for any ambiguity and for assessment of face validity. The HIV clinic appointment register was used to determine the routine visit days for the participants. Each participant was reassured of confidentiality, written consents obtained and questionnaire administered after the respondents had been assessed clinically and picked their drugs. This was to ensure that their due benefits were not denied them.
Grading of responses: current viral load results were abstracted from each patient´s hospital record and was considered as suppressed if <1000 copies of HIV ribonucleic acid (RNA)/millilitre of plasma or unsuppressed if >1000 copies of HIV RNA/millilitre of plasma . Perceived health status was assessed by asking the question “how is your health in general?” very good was scored 3, good was scored 2 and fair was scored 1 . Sexuality was analysed as sexual behaviour which was categorized as risky and non-risky sexual behaviour .
Operational definition for risky sexual behaviours- risky sexual behaviours are activities that will increase the probability that a person engaged in sexual activity with a partner who is infected with a sexually transmitted infection will be infected by the partner. In this study, risky sexual behaviours for HIV infection included use of substance before sexual activity, engaging in sexual activity without use of condom and having sex with more than one partner. A sexual behaviour was considered to be risky if the respondent had sex in the last 12 months but did not use condom or had multiple sexual partners or used substance before sex and non-risky if the respondent did not have sex in the last 12 months or the respondent had sex in the last 12 months but used condom, had only one sexual partner and did not use substance during sex [15-18]. A respondent was considered to have fertility desire if respondent intended to have a child or children in future and those who did not intend to have a child or more children in future were considered as not having fertility desires .
Knowledge of MTCT of HIV was assessed using six questions [20,21]. Each correct response was scored 2 and each incorrect response was scored zero. Respondents who had not heard of MTCT of HIV were scored 1 and same for respondents who did not know that MTCT of HIV could be prevented. A maximum attainable score was 12 while the minimum was 2. Over all knowledge was graded as good or poor. A score of 0-5 was considered poor knowledge while a score of ≥6 was considered as good knowledge.
Data processing and analysis: the statistical package IBM SPSS version 23.0 was used for data entry and analysis. Sociodemographic and medical related characteristics were presented in frequency tables and expressed as frequencies and percentages. Quantitative variable like age of the respondent was summarised using mean and standard deviation while others like duration of marriage, number of children, duration since knowing HIV status, duration on ARV drugs were grouped for the purpose of analysis. Knowledge on MTCT of HIV which is the explanatory variable was expressed using frequency table as frequencies and percentages. Also, the outcome variables fertility desire and sexuality were presented on frequency table as frequencies and percentages. Chi square test was done to determine the relationship between knowledge on MTCT and sexuality and also knowledge on MTCT and fertility desires of the respondents. Using a confidence interval of 95%, a p value <0.05 was considered to be statistically significant.
Ethical consideration: written permission was sought for and obtained from the Institutional Review Board of the SDA Hospital Jengre before proceeding with the study.
A total of 168 PLHIV participated in this study with more females (63.7%) than the males (36.3%), age ranging from 20 to 66 years with the average age of 39.35 ± 8.32 years. More than half (86.9%) of the respondents had 1-4 children. About two-third (67.9%) of the respondents had been on ARV drugs for more than 5 years prior to the study and greater than half (58.3%) of the respondents had partners with concordant HIV status. Most (72.6%) of the respondents considered their health status to be very good (Table 1). Majority (81.5%) of the respondents were sexually active and most (63.1%) of them were involved in risky sexual behaviours. More than half (63.5%) of the respondents did not use any form of modern contraceptive to prevent pregnancy. A small proportion (3.6%) of the respondents used substance before having sex. In addition, most (74.5%) of the respondents did not use condom during their last sex even though some of them had multiple sexual partners (Table 2).
About two-third (64.3%) of the respondents desired to have a child or more children in the future with more than half of them yet to achieve their desired family size. Use of ART increased the fertility desire in more than half of the respondents. Almost all (98.2%) the respondents have never discussed their fertility desires with their healthcare providers and none of the respondents had an idea on any safe method of conception aimed at reducing the risk of HIV transmission (Table 2). Concerning knowledge on MTCT of HIV, majority (62.5%) of the respondents had heard about MTCT of HIV. Knowledge on when MTCT of HIV can occur was poor as only 7.7%, 28.0% and 29.8% knew that it could occur during pregnancy, labour and breastfeeding respectively. Knowledge on whether MTCT could be prevented was also poor as only 28.0% of the respondents who had heard about MTCT knew that it could be prevented however 91.5% of this knew correctly how MTCT of HIV could be prevented. Overall knowledge on MTCT of HIV was poor with only 28.6% of the respondents having good knowledge (Table 3).
Among the 105 respondents who were aware of MTCT of HIV 67 of them were involved in risky sexual behaviour, while 38 of those who were not aware of MTCT were also involved in risky sexual behaviour. Also 60.8% and 66.7% of the respondents who had poor and good knowledge of MTCT respectively were involved in risky sexual behaviours also. This study did not find any statistically significant relationship between either the awareness of MTCT or knowledge on MTCT with sexuality of the respondents even though awareness was found among majority of the respondents (Table 3).
Thirty-seven (58.7%) of the respondents who were not aware of MTCT of HIV and 67 (64.2%) of those who were aware of MTCT had fertility desires. In addition, 76 (63.3%) and 30 (62.5%) of the respondents with poor knowledge and good knowledge of MTCT respectively also had fertility desires. This study did not find a statistically significant relationship between either awareness or knowledge of MTCT with the fertility desires of the respondents even though majority of the respondents were aware of MTCT and also majority had poor knowledge on MTCT of HIV (Table 3). Only 2 (3.3%) of the respondents without fertility desires stated that they did not want to infect their baby as reason for no fertility desire.
Majority of the respondents had disclosed their HIV status to their partners. Some of the respondents were in an HIV sero-discordant relationship while few did not know the HIV status of their partners. These findings were similar to the results of studies done in Ethiopia and Tanzania [11,22]. The findings on disclosure of HIV status in this study is however, higher than that observed in Togo . This may be as a result of the repeated counselling for PLHIV on their clinical visits to the hospital on the need for disclosure. Been in sero-discordant and unknown HIV status relationship increases the risk of HIV transmission.
This study found that majority of the respondents were sexually active and this was closely related to findings in Ethiopia , but was however higher in Tanzania, Togo, Denmark and Finland, Brazil, Democratic Republic of Congo, South Africa and Nigeria [22-28]. This may be due to the desire to have more children in the Northern part of Nigeria as a result of the dominant religion and also the practice of marrying more than one wife. This high rate of sexual activity found in this study is a concern since this can increase the risk of HIV transmission in sero-discordant partners and also re-infection of different strains of HIV for sero-concordant partners.
Condom use during last sex was very low as only a quarter of those who had sexual intercourse reported using condom. Low rates of condom use were also reported in Tanzania, Democratic Republic of Congo, Nigeria and South Africa [22,26,28,29]. Condom use was however, higher in studies in Ethiopia, Uganda, Brazil, Vietnam, Cameroun and Asia Pacific Region [11,15,25,30-32]. This low rate of condom use in this study may be due to the fact that most of the respondents were in sero-concordant relationship and may not had considered themselves at risk of re-infection but this however is a concern for partners who are in a sero-discordant relationship since they are at high risk of HIV infection. A very small proportion of the respondents used substance before sex and this was consistent with findings in Brazil and Togo [23,25].
Furthermore, having multiple sexual partners was revealed by this study and this was consistent with findings in Ethiopia, Togo, South Africa, Vietnam and Cameroun [11,23,27,30,31]. Also, close to two-third of the respondents did not use any form of contraceptive to prevent pregnancy and this was corroborated by result in Democratic Republic of Congo . This is a concern as it increases risk of vertical transmission and also horizontal transmission of HIV in sero-discordant relationships.
A little below two-third of the respondents in this study had fertility desires and this was found more among the females. This finding was consistent with reports in similar studies in Democratic Republic of Congo, Canada and Jamaica [26,33,34]. Respondents in other studies done in Addis Ababa, Eastern Ethiopia, Uganda, Tanzania, Brazil and Kenya were however, found to have lower fertility desires [2,11,12,15,25,35]. The difference with the findings of these studies may be due to the fact that fertility rate in Northern Nigeria is high .
Concerning awareness, most of the respondents had heard of MTCT of HIV. Knowledge on when MTCT of HIV can occur was very poor as not up to a quarter of the respondents knew that MTCT could occur during pregnancy, while a little above a quarter each among the respondents knew that it could occur during labour and delivery respectively. Knowledge on whether MTCT could be prevented was also poor as only about a quarter of the respondents knew that MTCT could be prevented and majority of these knew correctly how MTCT of HIV could be prevented. Overall knowledge on MTCT of HIV was poor with just about a quarter of the respondents having good knowledge. Similar study in Ethiopia also revealed that awareness of MTCT was good but knowledge was poor . In South Africa, West Ethiopia and Northwest Ethiopia [29,37,38] majority of the respondents were also aware of MTCT more than that of this study, but knowledge was also poor even though better than the findings of this study. This could be due to the fact that those studies were conducted among women attending ante-natal clinic (ANC) while our study included both men and non-pregnant women who most probably may never have had opportunity of receiving any education on MTCT since it is usually done in ANC settings.
This study did not show any association between either the awareness of MTCT or knowledge on MTCT with sexuality of the respondents even though awareness was good among majority of the respondents. This may be due to the fact that majority of the respondents were married and also to partners who are also living with HIV and therefore did not see any reason to adopt a non-risky sexual behaviour. It could also be due to the fact that all the respondents are all on ART and majority of them considered their health status as very good. This practice however, may increase the risk of MTCT considering the fact that majority of them did not use any form of contraceptive to prevent pregnancy. Also, no association was found between either awareness or knowledge of MTCT with the fertility desire even though majority of the respondents were aware of MTCT but with poor knowledge. This finding was consistent with study in Ethiopia . Only a very small proportion of the respondents without fertility desires stated that they did not want to infect their baby as a reason. This high fertility desires found in this study even with awareness of MTCT of HIV may also be due to their poor knowledge. Again, this study included men and single women who constituted more than one-third of the respondents and may not have knowledge of MTCT of HIV since it is not usual in the setting of this study for men to attend ANC with their partners.
Although this study showed high awareness and poor knowledge of MTCT of HIV, this however, did not affect the sexuality and fertility desires. Therefore, we recommend that information on MTCT of HIV be provided to PLHIV including men and single females by healthcare workers during routine clinic visits and not be limited to ANC in order to enable PLHIV make good decision about their sexuality and fertility desire to reduce HIV transmission risk.
Limitations of study: 1) sexual behaviour and practices are considered sensitive and personal issues in the Nigerian environment and so there could be some bias in the reported sexual practices. In order to control this, respondents were re-ensured of confidentiality on all information they provided for this study. Also, privacy was also ensured during interview session for each participant by attending to one participant at a time; 2) reported findings are limited by the validity of self-report and by possible recall bias. In order to reduce this, questionnaire was pre-tested on persons living with HIV who had similar characteristics with study participants in a different health facility to ensure quality of questionnaire. In addition, the research assistants who were involved in administering questionnaire were trained on the art of interview. Participants were also informed and re-assured about their anonymity as their names were not asked for in the course of the interview.
What is known about this topic
- PLHIV have fertility desire;
- PLHIV have risky sexual behaviour.
What this study adds
- Knowledge on MTCT does not affect sexuality in PLHIV;
- Knowledge on MTCT does not affect fertility desires in PLHIV.
The authors declare no competing interests.
Conception was done by Chikwendu Amaike and Blessing Adaku Amaike; design, data analysis, interpretation and data acquisition were done by Chikwendu Amaike, Hadiza Agbo, Tolulope Olumide Afolaranmi, Blessing Adaku Amaike and Olumide Abiodun; writing (review and editing) was done by Chikwendu Amaike, Tolulope Olumide Afolaranmi, Blessing Adaku Amaike, Olumide Abiodun and Hadiza Agbo; final approval of article was done by Chikwendu Amaike, Tolulope Olumide Afolaranmi, Blessing Adaku Amaike, Olumide Abiodun and Hadiza Agbo. All the authors have read and agreed to the final manuscript.
The authors are grateful to the respondents and also research assists who participated in data collection.
Funding: this study was funded by the authors.
Table 1: sociodemographic and medical-related characteristics
Table 2: sexuality and fertility desire of the respondents
Table 3: knowledge of MTCT and the relationship with sexuality and fertility desire
- World Health Organization (WHO) regional office for Africa. WHO Africa: health topics: HIV/AIDS. 2018.
- United Nation Programme on HIV/AIDS (UNAIDS). Country: Nigeria. Accessed on 10th November 2019.
- AVERT. Prevention of mother-to-child transmission (PMTCT) of HIV. 2019.
- Federal Ministry of Health Nigeria (National AIDS and STIs Control Programme). National guidelines for HIV prevention, treatment and care. Federal Ministry of Health, Abuja, Nigeria. 2016. Google Scholar
- AVERT. Global information and education on HIV and AIDS. 2017.
- General Conference of Seventh-day Adventists. Seventh-day Adventist Church yearbook 2017. Pacific Press Publishing Association. 2017;704. Accessed on 31st Aug 21.
- Plateau state Government. Bassa local government area: about Bassa. 2006.
- Government of Plateau State of Nigeria. Plateau state government house. Accessed on 10th November 2019
- Community Medicine for Academics and Lay Learners. Sample size calculation: cross sectional study. 2014.
- Nedjat S, Moazen B, Rezaei F, Hajizadeh S, Majdzadeh R, Setayesh HR et al. Sexual and reproductive health needs of HIV-positive people in Tehran, Iran: a mixed method descriptive study. Int J Health Policy Manag. 2015;4(9):591-8. PubMed | Google Scholar
- Adilo TM, Wordofa HM. Prevalence of fertility desire and its associated factors among 15- to 49-year-old people living with HIV/AIDS in Addis Ababa, Ethiopia: a cross-sectional study design. HIV AIDS (Auckl). 2017;9:167-176. PubMed | Google Scholar
- Ahmed MM, Kahsay AB, Miruts G, Berhe KK. Magnitude and factors affecting the fertility desire of people living with HIV infection in Ethiopia, a cross sectional study. J AIDS Clin Res. 2014;5(9):343. Google Scholar
- Organization of Economic Cooperation and Development (OECD). OECD health statistics 2016: definitions, sources and methods. 2014.
- Hadish MT, Mao Jing, Gong Guilan, Hadish BT, Tesfamariam EH. Predictors of high HIV/AIDS risk sexual behaviours: comparison study among Cameroonian and Gabonese youth aged 15-24 years. J HIV Retrovirus. 2017;3:1. Google Scholar
- Musinguzi G, Bwayo D, Kiwanuka N, Coutinho S, Mukose A, Kabanda J et al. Sexual behaviour among persons with HIV in Uganda: implications for policy and practice. PLoS One. 2014;9(1):e85646. PubMed | Google Scholar
- Wikipedia. Risky sexual behaviour.
- United States of America Department of Veterans Affairs. Sex and sexuality and HIV: entire lesson. 2019.
- Centre for Disease Control and Prevention. HIV and substance use. 2019.
- Wagner GJ, Wanyenze R. Fertility desires and intentions and the relationship to consistent condom use and provider communication regarding childbearing among HIV clients in Uganda. ISRN Infect Dis. 2013;2013:478192. PubMed | Google Scholar
- Abtew S, Awoke W, Asrat A. Knowledge of pregnant women on mother-to-child transmission of HIV, its prevention and associated factors in Assosa town, Northwest Ethiopia. HIV AIDS (Auckl). 2016;8:101-7. PubMed | Google Scholar
- Luba TR, Feng Z, Gebremedhin SA, Erena AN, Nasser AM, Bishwajit G et al. Knowledge about mother-to-child transmission of HIV, its prevention and associated factor among Ethiopian women. J Glob Health. 2017 Dec;7(2):020414. PubMed | Google Scholar
- Mmbaga EJ, Leyna GH, Ezekiel MJ, Kakoko DC. Fertility desire and intention of people living with HIV/AIDS in Tanzania: a call for restructuring care and treatment services. BMC Public Health. 2013;13:86. PubMed | Google Scholar
- Yaya I, Saka B, Landoh DE, Patchali PM, Makawa MS, Senanou S et al. Sexual risk behaviour among people living with HIV and AIDS on antiretroviral therapy at the regional Hospital of Sokode, Togo. BMC Public Health. 2014 Jun 22;14:636. PubMed | Google Scholar
- Wessman M, Aho I, Thorsteinsson K, Storgaard M, Johansen IS, Lunding S et al. Perception of sexuality and fertility in women living with HIV: a questionnaire study from two Nordic countries. J Int AIDS Soc. 2015;18(1):19962. PubMed | Google Scholar
- Ramos de Souza M, do Amaral WN, Alves Guimar„es R, Rezza G, Brunini SM. Reproductive desire among women living with HIV/AIDS in Central Brazil: prevalence and associated factors. PLoS One. 2017;12(10):e0186267. PubMed | Google Scholar
- Yotebieng M, Norris A, Chalachala JL, Matumona Y, Ramadhani HO, Behets F. Fertility desires, unmet need for family planning and unwanted pregnancies among HIV-infected women in care in Kinshasa, DR Congo. Pan African Medical Journal. 2015;20:235. PubMed | Google Scholar
- Huerga H, Venables E, Ben-Farhat J, van Cutsem G, Ellman T, Kenyon C. Higher risk sexual behaviour is associated with unawareness of HIV-positivity and lack of viral suppression- implications for treatment as prevention. Sci Rep. 2017;7(1):16117. PubMed | Google Scholar
- Ebuenyi ID, Ogoina D, Harry TC. Predictors of unprotected sexual intercourse among HIV-infected patients receiving antiretroviral drugs in the Niger Delta region of Nigeria. AIDS Care. 2018;30(3):296-299. PubMed | Google Scholar
- Ramoshaba R, Sithole SL. Knowledge and awareness of MTCT and PMTCT post-natal follow-up services among HIV infected mothers in the Mankweng Region, South Africa. Open AIDS J. 2017;11:36-44. PubMed | Google Scholar
- Vu TMT, Boggiano VL, Tran BX, Nguyen LH, Tran TT, Latkin CA et al. Sexual risk behaviours of patients with HIV over the course of antiretroviral treatment in Northern Vietnam. Int J Environ Res Public Health. 2018;15(6):1106. PubMed | Google Scholar
- Kuete M, Yuan H, He Q, Tchoua Kemayou AL, Ndognjem TP, Yang F et al. Sexual practices, fertility intentions, and awareness to prevent mother-to-child transmission of HIV among infected pregnant women at the Yaounde Central Hospital. Sex Med. 2016 Jun;4(2):e95-e103. PubMed | Google Scholar
- Deuba K, Kohlbrenner V, Koirala S, Ekstrom AM; CAT-S group. Condom use behaviour among people living with HIV: a seven-country community-based participatory research in the Asia-Pacific Region. Sex Transm Infect. 2018 May;94(3):200-205. PubMed | Google Scholar
- Loutfy MR, Hart TA, Mohammed SS, Su D, Ralph ED, Walmsley SL et al. Fertility desires and intentions of HIV-positive women of reproductive age in Ontario, Canada: a cross-sectional study. PLoS One. 2009;4(12):e7925. PubMed | Google Scholar
- Pottinger AM, Carroll Kamali. Reproductive needs of PLHIV in Jamaica: relationship between fertility desire, motives and depression. J Reprod Infant Psychol. 2019 Apr;38(1):38-48. PubMed | Google Scholar
- Wekesa E, Coast E. Fertility desires among men and women living with HIV/AIDS in Nairobi slums: a mixed methods study. PLoS One. 2014;9(8):e106292. PubMed | Google Scholar
- Ashimi AO, Amole TG, Abubakar MY, Ugwa EA. Fertility desire and utilization of family planning methods among HIV-positive women attending a tertiary hospital in a suburban setting in Northern Nigeria. Trop J Obstet Gyaenecol. 2017;34:54-60. Google Scholar
- Tesfaye G, Tufa B, Likisa J, Alebachew M, Temesgen G, Dinsa H. Knowledge, attitude and practice towards PMTCT of HIV among women attending Ambo Hospital ANC Clinic, West Ethiopia. J AIDS Clin Res. 2015;6:407. Google Scholar
- Ekubagewargies DT, Mekonnen HS, Siyoum TM. Assessment of knowledge, attitude and practice of HIV positive mothers on antiretroviral treatment towards infant feeding in Gondar Town health Institution, North West Ethiopia. Int J Pediatr. 2019;2019:9107989. PubMed | Google Scholar
- Mosisa G, Tsegaye R, Wakuma B, Mulisa D, Etefa W, Abadiga M et al. Fertility desire and associated factors among people living with HIV in Ethiopia: a systematic review and meta-analysis. Arch Public Health. 2020;78(1):123. PubMed | Google Scholar