ºÚÁÏÍø

Factors Influencing Pregnancy Decision Making among Known HIV Positive Women of Reproductive Age in Busia County, Western Kenya

¹Jhpiego Corporation, Nairobi, Kenya - An Affiliate of Johns Hopkins University, Kenya

²University of Eldoret, Department of Biological Sciences, Kenya

³Ministry of Health, Busia County, Kenya

*Corresponding Author:

Hudson Inyangala
Jhpiego Corporation
Nairobi, Kenya
An Affiliate of Johns Hopkins University, Kenya
Centre for Global Research RMIT Universit,Australia
Tel: 254721727398
E-mail: hudson.inyangala@jhpiego.org

Received date: September 06, 2016; Accepted date: September 16, 2016; Published date: September 30, 2016

Citation: Inyangala H, Makwali JA, Aluku SO (2016) Factors Influencing Pregnancy Decision Making among Known HIV Positive Women of Reproductive Age in Busia County, Western Kenya. J Preg Child Health 3:281. doi: 10.4172/2376-127X.1000281

Copyright: © 2016 Inyangala H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Kenya is one of the six HIV ‘high burden’ countries in Africa with about 1.6 million people living with HIV infection by 2013. Women in Kenya are more vulnerable to HIV infection compared to men, with the national HIV prevalence at 7.6% for women and 5.6% for men. There were about 1441 pregnant women living with HIV in Busia County in 2013, with an estimated 57 new paediatric infections. HIV positive mothers, have a constitutional; human right and may want to have children but the timing has to be right to minimize the chances of transmission. Aim: To establish the factors that influence pregnancy decision making amongst known HIV positive women of reproductive age in Busia County, Western Kenya. Methods: Desk review of existing PMTCT data in DHIS2, structured focused group discussions (FGDs) and health facility questionnaire based cross-sectional survey among known HIV positive pregnant women of reproductive age, and those with infants aged below 6 months attending antenatal (ANC)/PMTCT and child welfare clinics (CWC) were used. Results: Among the 128 women interviewed, 98 (77%) knew their HIV positive status prior to becoming pregnant, while 17 (13%) discovered their status at first ANC, 8 (6%) at labour and delivery and 5 (4%) at 2 weeks post-partum. Overall, the women shared similarities in their socio-demographic profile. Over 60% of the respondents were cognizant of the risk involved in getting pregnant. Regardless of women’s pregnancy experiences or intentions, considerations in pregnancy decision-making was based on desire for motherhood; religious values; stigma; attitudes of partners and health care providers. Conclusion: The younger HIV positive women, with 1 or 2 children were three times more likely to get pregnant than older ones (OR=2.67) despite their HIV positive status and the risks involved to fulfil societal concerns.

Keywords

Known HIV positive; Pregnancy

Introduction

Globally there are 40,385 new HIV infections weekly. Over 4,600 babies and 7,000 young women are infected each week [1]. In sub- Saharan Africa, women of childbearing age comprise 61% of people living with HIV, accounting for over 12 million women [2]. In Kenya, HIV incidence is increasing most dramatically among young women aged 18 to 30 years [3], which coincides with their peak reproductive years. Kenya has committed to eliminating new HIV infections among children by 2015, while keeping their mothers alive. This commitment is not on track.

Women of reproductive age are disproportionately affected by the HIV/AIDS epidemic, with women accounting for nearly 60% of people living with HIV in Busia County. The decision to get pregnant can be complex regardless of HIV sero-positivity, among HIV-infected women, however, getting pregnant introduces additional personal, public health, and clinical care concerns that must be addressed [4]. The vast majority of conceptions are unplanned and occur without the use of reproductive technologies such as sperm washing and artificial insemination. Thus, the unprotected sexual activity required for conception carries a significant risk of HIV transmission to uninfected sexual partner and the unborn child. Pregnancy among HIV positive women also carries a significant risk of vertical transmission during pregnancy, labour and delivery and post-natally through breastfeeding [4]. It is in view of these considerations that reproductive counselling sessions by most health care workers for people living with HIV, have largely been dissuasive, and HIV positive women who express a desire to have children continue to encounter the disapproval of health care workers. Although the potential negative health of the known HIV positive woman may have dampened the fertility intensions of known HIV positive women, the stigma associated with childlessness in the traditional African setting, the strong personal desire for biological parenthood remain potent drivers of the desire to get pregnant, despite a known HIV positive status. Indeed, in some cultural contexts remaining childless can be a violation of societal norms more stigmatizing than the HIV infection itself [5].

The HIV prevalence among women in Busia County is higher (8.4%) than that of men (5.1%) [3]. There were about 1,441 pregnant women living with HIV in Busia County in 2013 and 58% of HIV positive pregnant women in Busia County, do not deliver in a health facility, with only 41% of the pregnant women attending the recommended four antenatal visits [6]. This therefore means that there are critical missed opportunities to avail PMTCT interventions to mothers who need the service. There are about 58 new HIV infections annually among children in the county [6]. The mission of the national PMTCT program is the elimination of mother to child transmission (eMTCT) of HIV and keeping mothers alive by the year 2015 with a goal to reduce rate of MTCT of HIV to less than 5% (virtual elimination of HIV) and reduce preventable maternal mortality by 50%, with a vision of a HIV free society [6]. The PMTCT program is currently implementing the four pronged approach to prevention of mother to child transmission; prong one - prevent HIV among women of reproductive age before they get pregnant , prong two - prevent unintended pregnancies among women living with HIV. The third prong focuses on pregnant women who are already infected and demands that HIV testing be integrated into antenatal care, that they receive ARVs to prevent transmission of the virus and for their own health and that they are counselled adequately on the best feeding option for their baby. The fourth prong calls for better integration of HIV care, treatment and support for women found to be positive and their families. It has been observed that over 50% of the mothers enrolled in PMTCT program in four sites in Busia County, are known HIV positive. This situation raises fundamental questions about the second prong of PMTCT (family planning within HIV care and treatment settings), and or whether the correct guidance is offered to the mothers prior to conception. This is in light of the fact that approximately 78% of the pregnancies were unplanned [6].

Family planning and HIV programming intersect in a number of crucial ways with many women being simultaneously at the risk of both unintended pregnancy and HIV infection or re-infection. Countries with the greatest burden of HIV also have high levels of unmet need for family planning [7]. Like all women, HIV positive women have a right to make reproductive decisions free of coercion. It is their constitutional, human right to have children if and when they want. It is incumbent upon the health care system, health care workers to guide the mother on the safe timing along the continuum of care on when the risk of transmission of the virus is most minimal. This becomes a challenge given that most of the deliveries occur at home and most mothers start ANC late into the second or third trimester and that most of these pregnancies are unplanned.

For women with known HIV positive status who want to become pregnant, the use of antiretroviral prophylaxis during pregnancy can reduce mother-to-child transmission of HIV. They need to get as healthy as possible before becoming pregnant, start HIV treatment before pregnancy if they need it for their own health, or can start treatment during pregnancy to lower the risk of passing HIV to the baby, ensure that the baby is tested for HIV right after birth and initiating prophylactic treatment for the baby [8]. Afterwards, family planning services that promote healthy timing and spacing of pregnancies are important to reduce the risk of adverse pregnancy outcomes such as low birth weight, preterm birth and infant mortality [8]. For women with HIV who do not wish to become pregnant, family planning is a proven, cost-effective strategy for preventing mother-tochild transmission of HIV and therefore, reducing the number of new children needing HIV treatment, care and support [9]. The use of dual contraception, i.e., barrier methods of contraception (male or female condom) plus any other method, can protect against both unintended pregnancy and sexual transmission of HIV. Integration of FP and HIV services provides an opportunity to reach women and men at risk of, and living with HIV, with family planning information and services. This has been effectively done in Busia County with the support of partners including APHIAPlus Nyanza Western Project both at facility and community level. Jhpiego Kenya was responsible for implementing the RH/MNCH/FP, HTC and VMMC component of the APHIAPlus Nyanza Western Project. Family planning services, particularly in generalized epidemics, provide an opportunity to increase access to HIV counselling and testing and other HIV services [8].

The interconnectedness of the family planning and HIV/AIDS fields has long been recognized as a critical pillar in achieving sexual and reproductive health and hence the need to have integrated services that address the sexual and reproductive health needs of individuals in a holistic manner. Different models of integration are being pursued (e.g. family planning in HIV counselling and testing; family planning in PMTCT settings; and family planning in HIV care and treatment settings) and a variety of intervention approaches are being implemented. In Western and Nyanza region, the MCH model has been quite effective in integrating MCH; RH; FP and HIV services including provision of ART in MCH settings for not only the mother - baby pair but also the willing partner. HIV and FP integration services has taken major leaps with project teams training service providers on FP and HIV integration and also always discussing FP needs of the clients at the comprehensive care centre (CCC) level. It has been observed that health care workers (HCWs) give directive counselling for HIV positive women that encourages family planning and discourages further children.

Family planning use is similar for HIV positive and HIV negative women except in a few isolated incidences [10,11]. WHO guidance on family planning methods for HIV (Medical Eligibility Criteria - MEC) shows that HIV positive women are eligible for most of the available methods of family planning and can use them without much restrictions. Most HIV positive and HIV negative women intend to use contraceptives in the future and view several methods favourably [10,11]. Multiple factors influence how HIV positive women decide to use family planning. Helping HIV positive women and couples achieve their fertility intentions, including both preventing unintended pregnancies and planning desired pregnancies, requires that providers are able to offer evidence-based, informed choice counselling on the range of contraceptive methods that are safe for use by women with HIV. By preventing unintended births to HIV infected women, policymakers can amplify the impact of using antiretrovirals for pregnant HIV positive women to reduce infant HIV infection. It is important to also continue to guide HIV discordant couples wrestling with how to simultaneously plan future families and minimize HIV transmission risks.

Voluntary family planning (FP) is one of the most transformative interventions in global health, critical to improving women’s health and saving the lives of children in some of the World’s most vulnerable communities. Beyond the direct health benefits, FP is essential to women’s empowerment, and sustainable development, contributing to improvements in education, economic growth, and the prevention of mother to child transmission of HIV.

Preventing unintended pregnancy among HIV positive women is an effective approach to reducing paediatric HIV infection and vital to meeting HIV positive women’s sexual and reproductive health needs [11]. Although contraceptive services for HIV positive women is one of the four cornerstones of a comprehensive program for prevention of mother-to-child transmission of HIV, a review of PMTCT programs in Nyanza and Western shows between 47 and 60% of the mothers enrolled into the PMTCT program in various counties in 2015 were known HIV positive clients. Mentor Mothers, who have been on the forefront in educating the community, have also been observed to be getting pregnant. Mothers who have been on the PMTCT program and are about to be discharged at 18 months have been observed to get pregnant even before they are discharged. To better address the needs of women living positively with HIV and address their sexual and reproductive needs, there is need to ensure the dual reproductive health and HIV needs of women and couples are effectively met. This study aimed at determining the fertility intensions among known HIV positive women attending PMTCT clinics, including the interaction between providers and clients as well as HIV positive women’s fertility desires and demand for contraceptives.

Materials and Methods

Desk review of the existing PMTCT data in DHIS2 combined with FGDs and a questionnaire-based cross-sectional study was performed of known HIV positive pregnant women receiving prenatal, PMTCT care, and known HIV positive women with babies aged below 6 months attending CWC at four tier 2 facilities in Busia County from 1st January 2015 to 31st December 2015. The women were interviewed with a pretested questionnaire and through structured focused group discussions. Structured interviews, covering family planning needs, fertility intentions, were conducted in Kiswahili and the local language to establish the level of knowledge the mothers have on PMTC programming, whether the pregnancy was planned, unplanned or otherwise and whether there was an unmet need for family planning and the associated factors that may have influenced the known HIV positive woman to get pregnant. The study did not focus on the precautionary measures the mothers took to protect their spouse in the process of getting pregnant.

Ethical Considerations

After clearly explaining the purpose, aims, risks and objectives of the study to the potential participants, those mothers who were willing to participate were enrolled and required to sign a written consent. Participants had the right to refuse participation and that there was no coercion whatsoever. The study was designed in such a way that it was non-invasive and did not interfere with the participant’s way of life. Privacy and confidentiality were maintained.

Data Analysis

Quantitative data was coded, summarized and categorized by reducing a collection of written responses from the questionnaire to numerical codes, edited for completeness and accuracy and analysis done using the statistical package for social sciences (SPSS), after crosstabulations. The analysis was both descriptive and analytical using frequency distributions, cross tabulations aimed at ascertaining the pregnancy intentions of the known HIV positive mothers.

Results

A total of 128 women, attending clinics in four sites in Busia County, participated in the study. The ages ranged between 15-42 years with a mean of 28.4 years, SD=3.6 (Table 1). A total of 123 (96%) respondents were residents of Busia County with five (4%) of the mothers visiting relatives in Busia from the neighbouring counties of Bungoma and Kakamega. The sample was stratified between those in a relationship and or married (89%), single; divorced or widowed (12%). More than three quarters of the respondents (113 mothers; 88%) had a primary level education, while 12% had a secondary level education. There was one mother with middle level college education and none had university level education. The women had been living positively with HIV for an average of 4.6 years (range, 1-12 years). Among the 94 women with living children, the average number of children was 3.8 (range, 1-12) and the mean age of the children was 13.6 years (range - 11 months to 18 years). Of the 128 women sampled, 106 (83%) were pregnant, 22 (17%) had babies aged below 6 months (Table 1). For all of the women interviewed, the timing of diagnosis and the reproductive decision-making was unclear and indeed 78% of the pregnancies were unplanned (Table 1).

Table 1: Baseline Characteristics of known HIV Positive women Interviewed about Pregnancy Decision-Making (n=128).

The participants benefited from the knowledge gained from this study and any participant noted to have treatment adherence issues was referred for counselling. The mothers want a better life for their children, and will take into consideration the advice given to them by the HCWs. In the words of one woman: “I will do everything to protect my baby as advised by the nurse. I did it and had an HIV negative baby in the previous pregnancy and I am hopeful that this one will also be negative. The drugs and advice from the nurse works. I carry the medicine for my baby everywhere I go.” - said a 24 year old pregnant mother of one. “In our community, they value male children, I will observe what the nurse teaches us to try and get a male child to safeguard my marriage and family” added a 31 year old mother of two daughters. These highlights the social and cultural aspects that these mothers have to contend with.

Some of the known HIV positive mothers, who come in with subsequent pregnancies after a HIV positive diagnosis are “Mentor Mothers” who have gone through training using the Kenya Mentor Mothers Training package and are better informed on the issues around HIV and reproduction. They play a crucial role in educating the mothers at facility and community level. One of the mothers said “if our mentor mother is confident enough to get pregnant, and she is our teacher, it means that the PMTCT program is working and we also should not fear getting more babies so long as we follow the advice from the nurse and mentor mother” – said a 35 year old breastfeeding mother of four children.

Desk review of existing PMTCT data revealed that, in the year 2015 for Busia county, a total of 29,435 mothers were tested for HIV in PMTCT settings, 25,535 (87%) through ANC clinics, 3,568 (12%) at labour and delivery, while 438 (1.5%) were tested in the immediate postnatal period within 72 hours of delivery, while 106 (0.5%) declined the test [12]. During the same time period, a total of 1,732 mothers were identified HIV positive; 957 mothers were known HIV positive at entry into ANC , 594 tested HIV positive at ANC, 181 at labour and delivery, while 7 tested HIV positive in the immediate postnatal period. A total of 567 male partners accessed HIV counselling and testing services alongside their spouses at ANC and labour and delivery, 29 being discordant [12]. A total of 1,701 out of the 1,732 (98%) mothers were initiated on the recommended HAART at first contact. During the same time period, 49 babies were confirmed PCR positive (15 within 2 months, 24 between 3 and 8 months and 10 between 9-12 months), this loosely translates to MTCT rate of 2.9% [12]. A review of the reported infant feeding practices revealed that about 77% of the HIV exposed infants were exclusively breastfeed for 6 months, 7% had exclusive replacement feeding, while 4% had mixed feeding practices. According to the available 2015 PMTCT data, infant ARV prophylaxis, showed that 1,317 out of 1, 732 HIV exposed infants (76%) were issued with prophylaxis at ANC, 19% at labour and delivery while 1.6% were issued in the postnatal period within 72 hours. The reported eMTCT rates stands at 5.8% 9 months, 6.7% at 12 months and 7.6% at 18 months. This is way above the recommended national rate of 5% and the global goal of less than 2%.

The younger women aged below 24 years (n=42) were three times more likely to get pregnant than the older ones (OR=2.67). This was explained from the FGDs that it was a woman’s natural desire to get a baby and this age category had just one or two at most. The older women had an average of 4.6 children and were contended. Marital status was not significantly correlated to the desire to get a baby. The mothers explained that a woman whether married or not can get a baby whenever she desires. The women with a secondary level education and above were less likely to get pregnant than those with a lower level education (OR=0.78). The housewives and other women with no formal employment were three times more likely to get pregnant than those with stable income women with some source of income (OR=2.98). The woman with none or 1 child was more likely to get pregnant than the ones with 3 or 4 children (OR=1.76). This was particularly so because of pressure from the society and or the spouses.

The woman who had been living positively with HIV for four or more years was more likely to get pregnant than the one who was newly diagnosed (OR=1.54). This was explained by the mothers that this situation is as a result of the confidence they gain by knowing that ART works. Their health improves and they feel normal and hence the desire to have a baby. When they were initially diagnosed, they thought that that was the end of the road, but with treatment they realized that they can live a normal life and hence the need to get children, given more so that they got a HIV negative baby. The woman who had been on ART for long and was more stable had a higher odds of becoming pregnant than the newly initiated ones (OR=1.87). Approximately 78% of the pregnancies were unplanned. About 72% of the mothers interviewed from the four sites, had a HIV negative baby from the previous pregnancy and expressed confidence that they could get a second HIV negative one if they closely followed the instructions from the health care worker. This is in keeping with the County level data with MTCT rates of 5.8% at 9 months.

For religious reasons, the mothers who prescribed to the Catholic faith confessed not using contraceptives. But to protect their spouses, they admitted using condoms but infrequently, 88% were Protestants while 12% prescribed to the Catholic faith. Approximately 77% of the respondents reported using a modern method of contraception issued at the CCC or an alternative referral site.

Discussion

One of the goals of PMTCT programing is to increase the number of pregnant women who know their HIV status (both negative and positive), early identification of a pregnant woman’s HIV status is the key entry point into PMTCT services and other HIV care, support and treatment services. It is envisioned that the now known new HIV positive woman will be counselled and guided along her pregnancy and her future fertility concerns addressed accordingly. If she has no intentions of getting more children in future, then effective family planning options should be offered to her [13]. Collection of such data is important in identifying progress towards the overarching global elimination of MTCT goal of reducing the number of AIDS related maternal deaths by 50% and reducing the number of new HIV infections among children by 90%. The women interviewed in this study, presented a variety of pregnancy decision-making experiences. The main concerns hinged on the potential risk of vertical transmission to the baby, horizontal transmission to the partner, risk reduction strategies and outcomes of previous births that occurred after HIV diagnosis. These considerations were compounded by the demands by the partners and societal pressure to have children and the inherent stigma associated with being childless or barren.

The natural motherly instinct, the desire for motherhood, having children prior to diagnosis, opinions of partners, the wider society, HCWs, religious values and the perceived capacity to parent and take care of the new-born successfully regardless of HIV status also emerged from the women’s responses. Supporting other study findings, some women expressed strong beliefs that if their own health was poor, they would not consider pregnancy; women also were deterred by thoughts that they could become unable to care for a child because of illness, disability or death, and that pregnancy itself could worsen their health. The outcome of previous pregnancies influenced subsequent pregnancy intentions for some; having an HIV negative child gave some women confidence to become pregnant again, while others, relieved that their infant was HIV negative, did not want to take the risk again.

These findings, bring to the fore the interplay between sociocultural norms and biomedical considerations in pregnancy decision making among known HIV positive women. Approximately 78% of the pregnancies were unplanned due to condom failure or inconsistent condom use. Some pregnancies were associated with contraceptive failure or in some incidences non-use of the available pregnancy prevention methods including dual contraception. Reports of unintended pregnancies due to condom failure or a more passive approach to pregnancy prevention suggest a need for family planning counselling. The degree to which unintended pregnancies can be attributed to ambivalence, to feelings of decreased control or to other factors is unknown [13].

There are myths and misconceptions around contraception held by women generally. Most of these myths and misconceptions are also held by women living with HIV. Most of the respondents reported fear of side effects or drug interactions with the ART they are taking. Some reported that their husbands do not approve of the use of contraception and they have to use the method in hiding. This is also compounded by the fact that some mothers have not disclosed their status to their spouses. FP and ART also increases the pill load, and discourages the mothers from taking up family planning services. This contributes significantly to low uptake of family planning services. From the study findings, 80% of the mothers sampled were conversant with at least one method of family planning and this correlated closely with the actual FP users at 77%. The majority of the mothers (82%) indicated that they do not desire to have more children given their current serostatus and would instead concentrate on taking care of the surviving ones, some of whom were sick. Only 6.2% of the respondents reported knowing the HIV status of their spouses. All the sites sampled had all the family planning methods in stock except for the female condom that was out of stock in two out of the four sites. Two of the sites were able to offer the permanent methods of contraception (bilateral tubal ligation and vasectomy). The sites had well established network for referral for clients seeking methods that were not available on site.

In Kenya, it is estimated that approximately 18% of currently married women have an unmet need for family planning [14], which has declined from 26% in KDHS 2008/2009. This implies that about 18% of the known HIV positive mothers have contraception needs that are not fulfilled. The Contraceptive Prevalence Rate (CPR) for Busia county is 57.5% for any family planning method (National 58%), and 56.5% for any modern method (National 53.2%) with a total fertility rate (TFR) of 4.7% [14]. This is in keeping with the study findings, with 77% of the respondents using a modern family planning method. In Kenya, the TFR by education level, shows that women with a secondary level education and above desire to have 3 children, those with a completed primary level education 4.2 children, incomplete primary level incomplete 4.8 children, while those with no education at all desire to have 6.5 children per woman on average [14]. This situation has significant implications in PMTCT settings.

From the study 42 mothers were aged 24 years and below. The younger women aged below 24 years were three times more likely to get pregnant than the older ones (OR=2.67). Women were asked, “Did you intend to have this pregnancy or this child given your HIV positive status?” The overwhelming majority of HIV-positive women (82%) reported no, but decided to yield to societal pressure of having babies. About 8.9% of these mothers had had a HIV positive baby previously. The current Busia county MTCT rates are 5.8% and 7.6% at 9 and 18 months respectively. This then means that, in the current set up in Busia County, there is still a significant risk of MTCT of HIV. This is compounded by the fact that 78% of the pregnancies are unplanned and therefore no precautionary measures are taken and that 58% of the mothers deliver at home and may not have access to PMTCT interventions. And those that access PMTCT interventions have significant challenges around disclosure, adherence, care and support services. It is against this backdrop that Family Planning, the second prong of PMTCT programming is critical to prevent unintended pregnancies and help avert new paediatric HIV infections.

Many HIV positive women are reluctant to become pregnant because they fear they will pass the virus to their baby or that they will become too sick or disabled to care and provide for their children properly. But with counselling and guidance, along with comprehensive healthcare and treatment, many HIV positive women can have healthy, HIV negative children. The key to a successful pregnancy is the health of the mother-to-be. The HIV positive woman who is pregnant or is considering having children, has an additional reason to take care of herself, take medication, and have adequate nutrition, stop smoking, getting enough exercise, and not using recreational drugs including alcohol. The aim is a healthy pregnancy, an HIV negative baby, and a long, healthy life as a caring mother [4].

Studies done elsewhere by Siegel and Schrimshaw [15] examined pregnancy intentions of HIV infected women to become pregnant. The results indicated that women who purposely became pregnant after their HIV positive diagnosis possessed nine distinct characteristics. The characteristics were younger age; had increased motivation for childbearing; decreased perceived threat of HIV; decreased HIV symptomatology; higher traditional gender role orientation; greater avoidance coping; husband or boyfriend who wanted children; faith in God; and knew other HIV positive pregnant women. These findings are consistent with the FDG findings of the Busia study.

From the available literature, it’s still not clear when exactly HIV is transmitted during pregnancy. While some fetuses can be infected with HIV in utero, the vast majority of infections occur during labor and delivery, or through breastfeeding postnatally. Ideally, preparation for reducing risks to mother and child begins before conception, when the woman and her partner are deciding if, when, and how to have a baby. Without treatment, there is a 25% to 30% chance of an HIV positive woman passing the virus to her child “vertical transmission” [4]. Majority of the pregnancies are unplanned meaning that they just happened and no preparations were done [16]. This then means that there are no prior preparations done for the woman to plan the timing of her pregnancy in such a way that the risk of HIV transmission is reduced. Risk of mother-to-child transmission is generally dependent on the pregnant woman's viral load, the higher the amount of virus during pregnancy and delivery, the higher the chance of transmitting the virus to her baby.

Given the resource limited settings in Busia county and indeed all other counties in Kenya, low CPR, high HIV burden, poor health seeking behaviour, we would anticipate to have a situation where less and less known HIV positive mothers are getting pregnant and the few that do get pregnant, get the best possible PMTCT interventions leading to a favourable outcome of a HIV free baby. In these circumstances, there is need to balance the human and constitutional reproductive health rights aspect of things and the reality of high levels of the risk involved. Should a known HIV positive mother choose to become pregnant, then adequate measures need to be taken well before conception and the HCW should be able to guide the mother on the proper timing when the risk of transmission is the lowest as guided by the viral load and other clinical parameters? With good prenatal care and antiretroviral treatment, the risk of transmission can be reduced to less than 2%.

There are evidence based interventions at labour and delivery that can be used to minimize the risk of transmission including sperm washing (involving the separation the sperm from the seminal fluid that carries the virus, then using it to impregnate the woman when she is ovulating and most likely to become pregnant), integrated Pregnancy Care, use of antiretroviral therapy, treatment of other conditions related to or aggravated by pregnancy, avoiding amniotomies, episiotomies and birthing instrumentation and delivery via caesarian section [4]. These interventions however only benefit the woman who comes to deliver at facility level. The months following delivery of a baby by an HIV positive woman are also crucial to keeping the risk of vertical transmission to a minimum. Exclusive breastfeeding for 6 months is recommended. An HIV positive new mother usually wants to know right away whether her baby is infected or not. It can take several months to learn definitively the HIV status of a newborn, a situation that may change with the recently introduced testing guidelines. The new MoH guidelines recommend birth testing, defined as HIV testing (with DNA PCR) at birth or first contact within 2 weeks after birth, for infants born to known HIV positive mothers. Birth testing has the potential to greatly improve survival for infants who are infected during pregnancy and around labour and delivery by identifying them early for rapid ART initiation [17].

The study finding that women who were on HAART for longer durations were three times more likely to get pregnant, is in keeping with findings from other sub-Saharan African studies that have reported threefold higher childbearing intentions among HAART users and higher childbearing intentions associated with increasing duration of HAART use. Consistent with other studies of HIV positive and HIV negative women around the world, number of living children and current partnership status were also strongly associated with childbearing intensions. The study revealed that nearly one third of HIV positive women reported childbearing intentions, a proportion that increased significantly with younger age and fewer living children. All women, including women living with HIV, should be supported to achieve their reproductive goals in the healthiest and safest possible manner.

It is critical that factual and non-stigmatizing information and support be incorporated into HIV treatment services to optimize healthy outcomes for mother, the partner, and the baby. This includes counselling services regarding HAART and pregnancy, safer options to conceive (including HAART as prevention and pre-exposure prophylaxis – PrEP, for the negative partner in a discordant relationship), safer labour and delivery options, comprehensive PMTCT services, ANC and PNC as well as infant feeding options. Currently, no clear guidelines are available regarding the ideal time for pregnancy for an HIV positive woman (with respect to CD4 level, stage of treatment, treatment regimen, and viral load, or HIV and health status of her partner). Conception requires unprotected sexual activity, and the HIV status of the sexual partners for many of these women is unknown (only 6% had known HIV status of the partner). The majority of the women (78%) had unplanned repeat pregnancies with known HIV positive status. The study findings revealed that husbands or spouses, contributed greatly to pregnancy decisionmaking with 56% of the respondents reporting that their pregnancy were due to pressure from their husbands, partners, significant others basically bowing to societal pressure.

This scenario is compounded by the low levels of male involvement during ANC and FP counselling sessions generally and after an HIV positive test in particular. The none participation of the male partners in FP counselling after an HIV test, makes it difficult for the women to negotiate for safer sex, the woman has to use the method in hiding. Male involvement has long been accepted as key to FP acceptance and adherence since men are the decision makers in many of the African settings. Pregnancy decision making is complicated for HIV positive women, they must contend with unpredictable symptoms and prognoses, the potential for vertical transmission and often problematic life contexts such as poverty, substance and alcohol abuse and stigma that may compromise parenting as well as intimate partner violence.

Conclusion

The fertility intentions of known HIV positive women in Busia county demands that integrated HIV care, treatment and support services and reproductive health services be made available to support the rights of HIV positive women to safely achieve their childbearing goals, while minimizing risks of vertical and horizontal transmission. PMTCT programming should give a special focus to the younger mothers, and those who have been on HAART for long, reach them with adequate information, counselling and reproductive health services.

Recommendations

Conduct more health education sessions for the ANC mothers. Avail family planning information and services with emphasis on dual contraception. Continue to strengthen FP and HIV integration of services. There is need for more intensified education to encourage women living with HIV to embrace dual contraceptive, especially longer acting contraceptive methods in order to reduce barriers associated with misconceptions associated with these family planning methods.

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