title: Fertility and HIV following universal access to ART in Rwanda: a cross-sectional analysis of Demographic and Health Survey data.
abstract: BACKGROUND
  HIV infection is linked to decreased fertility and fertility desires in sub-Saharan Africa due to biological and social factors. We investigate the relationship between HIV infection and fertility or fertility desires in the context of universal access to antiretroviral therapy introduced in 2004 in Rwanda.
  
  
  METHODS
  We used data from 3532 and 4527 women aged 20-49 from the 2005 and 2010 Rwandan Demographic and Health Surveys (RDHS), respectively. The RDHSs included blood-tests for HIV, as well as detailed interviews about fertility, demographic and behavioral outcomes. In both years, multiple logistic regression was used to assess the association between HIV and fertility outcomes within three age categories (20-29, 30-39 and 40-49 years), controlling for confounders and compensating for the complex survey design.
  
  
  RESULTS
  In 2010, we did not find a difference in the odds of pregnancy in the last 5 years between HIV-seropositive and HIV-seronegative women after controlling for potential biological and social confounders. Controlling for the same confounders, we found that HIV-seropositive women under age 40 were less likely to desire more children compared to HIV-seronegative women (20-29 years adjusted odds ratio (AOR) = 0.31, 95% CI: 0.17, 0.58; 30-39 years AOR = 0.24, 95% CI: 0.14, 0.43), but no difference was found among women aged 40 or older. No associations between HIV and fertility or fertility desire were found in 2005.
  
  
  CONCLUSIONS
  These findings suggest no difference in births or current pregnancy among HIV-seropositive and HIV-seronegative women. That in 2010 HIV-seropositive women in their earlier childbearing years desired fewer children than HIV-seronegative women could suggest more women with HIV survived; and stigma, fear of transmitting HIV, or realism about living with HIV and prematurely dying from HIV may affect their desire to have children. These findings emphasize the importance of delivering appropriate information about pregnancy and childbearing to HIV-infected women, enabling women living with HIV to make informed decisions about their reproductive life.
authors.affiliation: Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda. ericremera@gmail.com.
authors.forename: Eric
authors.identifier: http://orcid.org/0000-0002-6084-8877
authors.initials: E
authors.lastname: Remera
authors.affiliation: Centers for Disease Control and Prevention, Kigali, Rwanda.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Boer
authors.affiliation: College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda.
authors.forename: Stella M
authors.initials: SM
authors.lastname: Umuhoza
authors.affiliation: College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda.|Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.|Inshuti Mu Buzima/Partners in Health, Rwinkwavu, Rwanda.
authors.forename: Bethany L
authors.initials: BL
authors.lastname: Hedt-Gauthier
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
authors.forename: Dana R
authors.initials: DR
authors.lastname: Thomson
authors.affiliation: Centers for Disease Control and Prevention, Kigali, Rwanda.
authors.forename: Patrick
authors.initials: P
authors.lastname: Ndimubanzi
authors.affiliation: Centers for Disease Control and Prevention, Kigali, Rwanda.
authors.forename: Eugenie
authors.initials: E
authors.lastname: Kayirangwa
authors.affiliation: National Institute of Statistics Rwanda, Kigali, Rwanda.
authors.forename: Salomon
authors.initials: S
authors.lastname: Mutsinzi
authors.affiliation: Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Alice
authors.initials: A
authors.lastname: Bayingana
authors.affiliation: Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Placidie
authors.initials: P
authors.lastname: Mugwaneza
authors.affiliation: Centers for Disease Control and Prevention, Kigali, Rwanda.
authors.forename: Jean Baptiste T
authors.initials: JB
authors.lastname: Koama
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001294:Attitude to Health; D003430:Cross-Sectional Studies; D005260:Female; D005298:Fertility; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000635:transmission*; D015497:HIV-1 / Q000472:pathogenicity; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008875:Middle Aged; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology / Q000517:prevention & control*; D012432:Rwanda / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: Africa; DHS; Evaluation; PMTCT; Women’s health