March 2001, Vol. 7, No. 1

Reproductive Health
Does HIV Affect Reproductive Choices in Zambia?

Do people alter their reproductive behavior in response to HIV/AIDS in settings where infection is prevalent? Are there ways that reproductive health and family planning services can help people make choices to reduce the risk of perinatal and heterosexual transmission of HIV/AIDS? Naomi Rutenberg, Population Council senior program associate, and her colleagues investigated these questions in Ndola, Zambia.

The situation in Ndola
HIV infection rates are as high as 20 percent among adult men and 30 percent among adult women in Ndola. The city serves as an entertainment and supply base for a substantial number of miners, seasonal workers, and truck drivers—a circumstance that fuels the HIV epidemic there. To assess the knowledge and attitudes of adults in Ndola, Rutenberg and her team conducted eight focus groups with a total of 76 participants and 23 in-depth interviews.

The researchers found that most participants were highly aware of and concerned about HIV/AIDS. These concerns, however, were not reflected in their decisions about childbearing. In fact, most people expressed confusion about how the presence of HIV would affect these decisions unless a person knew he or she was infected.

Economic factors have the most important influence on childbearing decisions, according to participants. In some cases, these economic factors are influenced by HIV/AIDS, such as when families adopt the children of relatives who have died of the disease. The extra burden raising orphans would impose often leads couples either to limit their own childbearing or to refrain from fulfilling their obligations to care for relatives’ children.

Behavior change and perception of HIV risk
Interviewees were asked whether they personally felt at risk for HIV infection. More than half felt that they were not at risk for contracting HIV, usually because they were “well behaved” or they and their partner trusted each other. A substantial minority of participants, however, thought they might be at risk. One 34-year-old woman stated, “I would not know about my husband’s movements while myself, I am innocent, so it worries me.” Many wives said they hesitated to raise the issue of HIV prevention for fear that their husbands would assume the women were being unfaithful, though the wives believed they could insist that their husbands use condoms in extramarital relationships.

The majority of respondents said that pregnancy prevention and condom use would be necessary if someone knew he or she had HIV or showed signs of illness. There was clear consensus from the participants that pregnancy in an HIV-positive woman would lead to a rapid deterioration of her health. Additionally, the vast majority of participants felt that the child would undoubtedly be born infected with HIV and die. Only a few respondents were aware that not all babies born to HIV-positive mothers become infected. One female focus group participant explained, “That is how it is when a woman is pregnant—that is when all the diseases in the body come out and make HIV because the disease is already in the body. Soon after delivery, everything just comes out and the baby does not live long, it dies, and for the mother also the disease becomes very serious.”

Most respondents felt that condom use would be the best method of avoiding pregnancy if a woman knew she was HIV-positive. Participants reported that in such cases the stigma about condom use would be reduced and the need to negotiate use minimized. Evidence of such changes in reproductive behavior has not been found by other studies in the region, however; such studies show that knowledge of one’s HIV status sometimes influenced later contraceptive use but not subsequent fertility. HIV-positive women may be giving birth when they would prefer not to. If they could avoid such births without facing stigma, they probably would do so.

Research and policy recommendations
Rutenberg and her colleagues conclude that we need to find out more about the factors that influence women and couples infected with or affected by HIV to continue childbearing. In the meantime, the investigators suggest that family planning and reproductive health clinics encourage women and men to evaluate their risks of contracting HIV and to consider having a free, voluntary HIV test.

“While knowledge of one’s HIV status may not be sufficient to influence fertility decisions, it is a necessary first step for making an informed choice,” states Rutenberg.

Clinicians should also emphasize concerns about children’s well-being. Suggesting behavior change for this reason may resonate more strongly with couples than do other rationales, such as preserving individual health. Finally, once a couple affected by HIV decide to avoid pregnancy, providers must be equipped to help them consider the benefits and drawbacks of various contraceptive methods.

Sources
Rutenberg, Naomi, Ann E. Biddlecom, and Frederick A.D. Kaona. 2000. “Reproductive decision-making in the context of HIV and AIDS: A qualitative study in Ndola, Zambia,” International Family Planning Perspectives 26(3):124–130.

Outside funding
The Rockefeller Foundation and the United States Agency for International Development

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