Factors affecting fertility desires and intentions of HIV Positive Men and Women in Post-conflict Northern Uganda: a mix

1. Factors affecting fertility desires and intentions of HIV Positive Men and Women in Post-conflict Northern Uganda: a mixed methods study Barbara Nattabi Primary Supervisor: Dr Jaya Earnest Co Supervisor: Dr Sandy Thompson Co Supervisor: Dr Jianghong Li Associate Supervisor: Dr Christopher Garimoi Orach

2. Presentation • Context: Uganda, Northern Uganda, Researcher • Research questions, objectives and background • Literature review • Significance • Methodology • Ethical considerations

3. Uganda • East Africa • 30 million people • High fertility rate: 7 children per woman • Adult HIV prevalence 6.7% (UNAIDS 2006) • Women are 52% of HIV population • 2.3% males, 5.0% females 15-24 age group are HIV positive • MTCT 21% of HIV transmission

4. Northern Uganda • 2 decade civil conflict • LRA rebels vs. Uganda Government • Acholi region and Lango region • 1.5 million displaced into IDP camps • Malaria, TB, Cholera, Hepatitis E, HIV/AIDS, Ebola • HIV prevalence 8.2%, higher than other rural areas: 2.3%

5. Prevalence of HIV Infection among ANC attendees in major towns in Uganda

6. Context of researcher • Medical doctor since 1997. Worked at St. Mary’s Hospital Lacor in Gulu district up to 2006. • Public health specialist since 2001. • For 4 years in-charge of HIV/AIDS department: VCT, PMTCT, ART programs, HIV surveillance and Research.

7. Context of researcher • WHO National Disease Control Officer 2006-2007 in Kitgum district, Northern Uganda.

8. Background to research study • ‘Successful’ ART program supported by PEPFAR • 1,000 people on branded drugs • Good outcomes: improved CD4 counts, reduced viral loads, ‘Lazarus’ effects • Other issues began to come up: sexual activity, pregnancies • Flabbergasted doctors, nurses, community workers: worried about MTCT, sexual transmission

9. AIDS Patients in Northern Uganda

10. Research questions: • What are the fertility desires and intentions of HIV infected men and women in post-conflict Northern Uganda • What are the factors that influence their reproductive decision-making? Why do they make these decisions and choices? • Based on their desires and intentions, what are their needs as regards HIV prevention and care programs? • What family planning services are available to HIV infected women and men in Northern Uganda and how accessible are they?

11. Research objectives: • To describe and explore the determinants of fertility desires and intentions of the HIV infected women and men attending three HIV clinics in Gulu district • To investigate access to family planning services among HIV infected women and men attending three HIV clinics in Gulu district and explore the structural/environmental, community and individual factors that enhance or restrict their ability to plan, space and limit their family sizes. • To investigate the level of integration of family planning services with HIV/AIDS Programs at health facility and national program levels • To suggest an appropriate model for delivery of family planning services to the HIV infected women and men attending these HIV clinics in Gulu district, with possible implications for HIV positive populations in other regions in Uganda

12. Literature review 1 • Mainly quantitative studies • HIV affected couples desire to have children • Continue to have children, regardless of the risks • 30% had become pregnant since receiving their diagnosis • 25% desired to have children with >50% of both women and men actually intending to have one or more children in the future • Variables associated with pregnancy desire in HIV positive women: PMTCT knowledge, younger age of mother, having few children, subjective higher ratings of overall health, male

13. Literature review 2 • Few qualitative studies • Six themes related to reproductive decisions : spiritual and religious beliefs, knowledge and beliefs about HIV, previous experience with child bearing, attitudes of families and sex partners, personal health interpersonal motivation to have a baby • Determinants of the desire to have more children: • Wanting to raise children as a way to give them purpose in life • As a way to regain their sense of womanhood and sexuality • A need to satisfy a partner’s desire to have a child • Potential for motherhood was more influential on procreative decisions vs. the health risks to mother and child • Family, spouses and societies expectations for childbearing

14. Literature review 3 In contrast: • Other studies have found that HIV-positive women who are aware of their status are less likely to want to have a child in the future • Only 7% of HIV-positive women who knew their status wanted to have a child • In Kenya, eight times less likely to want to have children • concerned about their own health, • worried that more pregnancies would make them deteriorate faster • felt that they should take care of their existing children • worried about transmission of HIV to future children

15. SIGNIFICANCE OF THE STUDY • First of its kind in post conflict Northern Uganda • Provide deep insights into fertility desires and intentions • Add to the discourse on HIV infected men and their desires • Combination of qualitative and quantitative data to provide a more holistic dimension. • Provide information on programmatic needs • Provide new information on how family planning services can be further integrated with HIV prevention and care services in Northern Uganda • Provide better knowledge of the family planning preferences and culturally appropriate models of service delivery.

16. Quantitative data collection: Questionnaires Qualitative data collection: In-depth Interviews Quantitative data analysis: Descriptive and Inferential statistics Qualitative data analysis: Thematic content analysis Quantitative results Qualitative results Compare and contrast Interpretation Quantitative and Qualitative Research methodology • Mixed methods: quantitative and qualitative • Triangulation: Convergence model (Creswell 2007) • Equal emphasis for both arms • Concurrent and separate data collection, analysis • Results will be compared and contrasted • Final interpretation

17. Phases of study

18. Quantitative arm • 400 respondents • Males and females • 15-49 age group • Stratified by age and gender • Consecutive enrolment • Outpatients in 3 hospitals in Gulu district • Structured Questionnaire based on the UDHS 2006: socio-demographic information, sexual and reproductive history, fertility desires and intentions • Analysis: Uni, Bi, Multivariate analysis • SPSS and EpiInfo

19. Qualitative arm • 10 respondents • Purposive sampling • In-depth interviews • Semi-structured guide • Tape recording • Transcribe and Translation • Analysis in Nvivo • Thematic content analysis

20. Ethical considerations • Approval from the Curtin University Human Research Ethics Committee, Uganda National Council for Science and Technology. • Informed consent: objectives, procedures and implications of the study. • Allowed to reach a rational, autonomous decision and will not be coerced to join the study. • Information sheet and informed consent form. • Free to withdraw at any stage in the study. • Confidentiality • Interviews in a private room AIDS clinic and in-depth interviews will be held in the privacy of the respondents’ homes. • Possible psychological harm may arise: participants will be referred to senior counselors

21. Thank you for listening Questions?