Reproductive aspects and knowledge of family planning among women with Acquired Immunodeficiency Syndrome

3 Universidade Federal do Ceará, Departamento de Enfermagem, Fortaleza, CE, Brasil. ABSTRACT Objective: To analyze the reproductive aspects and knowledge of family planning among women with Acquired Immunodeficiency Syndrome (AIDS). Method: Crosssectional and descriptive study carried out from January to December, 2015, in the outpatient care of infectious disease unit in a hospital located in Fortaleza, Ceará. Data were collected through a form applied by interview in a private setting. Results: 102 women participated in the study. Most were aware that they were serologically positive with human immunodeficiency virus (HIV) during prenatal care (96.1%) and did not intend to have more children (63.7%). Women who were less than 39 years of age, had a higher educational level, and a shorter time of antiretroviral therapy had better chances of having children (p≤0.05). Having a steady partner increased the chance of desiring to have children, while tubal ligation was higher among women that did not receive counseling on family planning. Knowledge of family planning was limited because of lack of assistance provided by health professionals.


INTRODUCTION
There are 36.7 million people around the world living with acquired immunodeficiency syndrome (HIV), and the number of infected women represents more than half of this population (1) .Access to antiretroviral therapy (ART) has been significantly expanded, providing improvement in the quality of life and an increase in survival rates for people with HIV and Acquired Immunodeficiency Syndrome (AIDS), and raised challenges aimed at guaranteeing total health for these individuals (1)(2) .In this regard, a decrease in morbimortality and an increase in the number of women of reproductive age with HIV/AIDS have been seen, which led to broadening the discussion on family planning (2)(3) , with the aim of maintaining the health of women, safeguarding reproductive rights, avoiding unintended pregnancy and maternal death, and preventing virus spread and vertical transmission (4) .
Brazil is renowned for having a national program for HIV/AIDS that guarantees antiretroviral drugs free of charge and sustainably for everyone with HIV/AIDS, including pregnant women, in addition to offering quick testing and serology for detecting HIV in pregnant women (5) .Despite these achievements, there are social inequalities among the regions of Brazil related to virus detection rate in this population.In the Northeast region, detection rates for HIV are the lowest, and pregnant women have the poorest education and hence are the most affected in the country (6) .As a consequence, there is a lack of information about the factors that affect the wish to have children among these women, as well as the use of contraceptive methods, in this Brazilian region.
Evidence suggests that, despite the possibility of women with HIV/AIDS having a healthy and reasonable sexual and reproductive life, there are challenges related to access to sexual and reproductive rights and health services, including the provision of contraceptive methods (7) .Furthermore, barriers such as lack of female decision power, a shortage of human and material resources, and poor quality of family planning services increase women's vulnerability related to reproductive aspects.
Most studies on the reproductive aspects of women with HIV/AIDS were developed in African nations (8)(9)(10) , where the highest incidence of cases is concentrated.It is important to emphasize that the Brazilian scenario is not different, taking into account that it concentrates the highest number of HIV/AIDS cases in Latin America (11) , which exposes the need to evaluate the reproductive aspects of these women.Based on the above considerations, the objective of this study was to analyze the reproductive aspects and knowledge of family planning among women with AIDS.

METHOD
This was a cross-sectional, descriptive, and quantitative study developed in the infectious disease outpatient unit of a university hospital in Fortaleza, state of Ceará, Brazil from January to December, 2015.The referred hospital assists adult patients with HIV/AIDS, and provides ART, laboratory exams and imaging, and condoms.Taking into account the population of women with AIDS monitored by the health service during the study period, the following formula for a finite population sample calculation was applied: In this formula, z is equal to the statistical value of z (1.96) for confidence level adopted (95%) and p, N e e correspond to the presumed prevalence (0.50) for the population of women monitored by the service (135) and for the tolerable error (0.05), respectively.Therefore, a sample of 102 patients was calculated.
The inclusion criteria were: women with AIDS; age equal or greater than 18 years; and regardless they had a sexual partner (steady or casual).Pregnant women and those under conditions that could interfere with the comprehension of the researched information were excluded.Convenience sampling method was used for selecting the participants, and women were invited to participate in the study as they showed up at the care service for their appointments.For data collection, interviews of 50 minutes' duration were conducted in a private setting, applying a form with the variables: social-demographic and clinical data; contraceptive methods in use; reproductive background; and family planning knowledge.
Absolute and relative frequency, average, and standard deviation (SD) for the quantitative variables were calculated.Statistical associations as dependent variables were considered: wish to have children; whether they have children; counseling on family planning while living with HIV.In addition were the answers to the questions: With HIV, is possible to have children?Can a seroconcordant couple have children?The remaining variables were listed as independent.The association between the categorical variables was carried out with the chi-squared test for the independent variables, odds ratio (OR) value, and a confidence interval (CI) of 95%.A p-value of <0.05 value was considered statistically significant.Data were tabulated using Excel software and analyzed with software R, version 3.2.2.
The study was in conformity with the ethical and legal aspects of Resolution nº 466/2012 of the National Health Council regarding studies that involve human beings.The research was approved by the Ethics Research Committee of Walter Cantídio University Hospital on March, 9, 2015, under approval number 992.484.
Most were diagnosed with HIV during the prenatal period (96.1%), and after the birth of a child exposed to HIV, more than half (63.7%) decided not to have more children.The majority had children at the time of the interview (84.3%), with a predominance of one to two children (51.9%), and only one revealed that the anti-HIV serology of her child was positive.Most had a steady partner (75.0%) that knew of her serological situation (73.5%).The use of male condoms (58.8%) and poor use of oral contraceptives (23.5%) were highlighted (Table 2).
Despite the fact that the majority of the women believed that they might have to have children living with AIDS (78.4%),only one-third (33.3%) revealed having received counseling on family planning, while more than half were not aware of the forms of vertical transmission (55.9%).Regarding the influence of the partner's serology in terms of conception, most believed that seroconcordants could have children (53.9%), but serodiscordants could not (52.0%)(Table 3).Women with steady partners had a higher chance of wishing to have children (p=0.04;OR=1.34;CI 95%=0.4-4.9),but those with one or more children (p=0.01;OR=1.50;CI 95%=0.4-5.2) or who had undergone tubal ligation (p=0.01;OR=0.16;CI 95%=0.0-0.6) had decided not to have more children.Tubal ligation was higher in women that did not receive counseling on family planning while living with HIV (p=0.03;OR=5.35;CI 95%=1.4-38.4)(Table 4).Women of age ≤39 years and with a higher educational level had better chances of receiving correct information about the possibility of having children while living with HIV (p = 0.01; OR = 0.22; CI 95% = 0.1 -0.6).These same women answered that seroconcordant couples could have children (p = 0.00; OR = 0.27; CI 95% = 0.1 -0.6).The "have children" variable showed a statistically significant association with age (p = 0.05; OR = 3.44; CI 95% = 1.1 -12.0), educational level (p = 0.04; OR = 5.61; CI 95% = 1.4 -41.0), and ART time (p = 0.01; OR = 0.11; CI 95% = 0.0 -0.6).That is to say, women of age ≤39 years, higher educational level, and ART time of use less than or equal to five years had better chances of having children (Table 5).

DISCUSSION
The predominance of age lower than 39 years, steady relationship, and low household income among the study participants showed that women of reproductive age and socio-economic vulnerability were exposed to the virus through sexual transmission, in conformity with other studies (4,(12)(13) .According to the current research, after diagnosis women with HIV/AIDS continued working actively to guarantee the income of their children and partners (14) .
In this study, most of the women declared that they had more than 10 years of education, which justifies the fact that some interviewees were aware of general information on family planning while living with HIV, indicating a better chance to understand and adhere to the recommendations regarding contraception.This higher level of education diverges from studies carried out in Africa (8)(9) , where access to education is limited.
Most of the women in this study had lived with HIV for more than three years and had been using antiretroviral therapy since the diagnosis.Furthermore, they had learned of their serology during prenatal follow-up.This confirms the need at the national level for diagnosis and treatment with antiretroviral drugs among pregnant women and women of reproductive age (5) , an important indicator for preventing vertical transmission of the virus.It should be mentioned that these same clinical characteristics were also found among African women (14)(15) .
Considering that the discovery of infection among the current study participants took place during a prenatal examination, more than half of the women with HIV/ AIDS already had one or two children at the time of the interview, a number similar to that found in other studies (10,(13)(14) .Evidence shows that maternity is an important motivation for women with HIV/AIDS to continue with their life plans and adhere to the treatment (15) .
Despite the fact that most of the women with AIDS were within reproductive age and had active sexual lives, many did not want to have children in the future, a similar finding to that of other studies (9)(10)12) . In te current research, this aspect could be associated with the fact that women have a lower household income, already had children, or it could be related to the lack of opportunity to discuss aspects related to reproduction with health professionals.Corroborating evidence shows that the option of not having children could be related to financial difficulties, because these women already have the number of children they consider adequate, because of the stigmatization in part of family members and health professionals, as well as concerns related to their children becoming orphans, vertical transmission, and serodiscordant partners (15)(16) .
Regarding family planning, most of the interviewees were not using contraceptive methods according to the standards for people with HIV/AIDS, which are the use of condoms in all sexual relations.This increased the risk of undesired pregnancy as well as HIV reinfection.What was highlighted was one individual's use of male condoms; however, this percentage was considered low, taking into account that 100% adherence is expected among these individuals.This low adherence to condoms matches the results of other studies (7,14,(16)(17) .It emphasizes the need for health professionals to investigate the barriers to the adequate and consistent use of condoms as a self-care measure for preventing sexually transmitted infections (STIs) (18) .Some interviewees used oral contraceptives, which could indicate low access to this method by women being followed up at the outpatient unit (17) or concerns related to the possibility of drug interaction with the ART (19) .Furthermore, an oral contraceptive is one more pill to be swallowed daily, with the possibility of unleashing adverse events such as nausea and irregular vaginal bleeding, contributing to the discontinuity of its use (20) .Because hormonal contraception for women with HIV is a safe and unrestricted measure, health professionals should recommend the combination with condoms for preventing both undesired pregnancy and STIs (21) .Regarding tubal ligation, its lower percentage of usage converges with the literature (14) .However, it is necessary to motivate the adherence of Brazilian women with HIV/AIDS to non-defined methods.Furthermore, the possibility of a reduction in the adherence to condoms after tubal ligation indicates the importance of counseling on the continuity of their use for avoiding HIV reinfection and the acquisition of other infections (22) .
Although Brazil has a policy for prevention of vertical HIV transmission (22) , there is a gap related to receiving counseling on the forms of prevention of transmission and reproduction for those living with HIV, a similar situation found in studies conducted in African nations (16,23) .It is clear that women with HIV/AIDS are reluctant to talk about sexuality and their reproductive desire for fear of a negative reaction on the part of health professionals.These professional oftentimes consider the wish to have children as an act of irresponsibility and lack of information on the risks of HIV vertical transmission (24) .This is a disturbing finding, because limited knowledge may hamper the wish and the rights of women with HIV/AIDS to have children, thus increasing the risk of unplanned pregnancy and newborn exposure to the virus (9) .
This study revealed that women that did not receive information on family planning are more likely to have a tubal ligation, which can be linked to their limited knowledge and myths about other contraceptive methods.Therefore, it shows the need for health professionals to offer counseling to women with AIDS regarding the options, benefits, and risks of each method to promote their autonomy during decision-making (2,15) .
converging with the systematic review on fertility in people with HIV (2) , which indicated that young women are biologically more likely to have children, and those with higher educational levels have more access to information on reproductive rights and prevention of vertical transmission (23) .
Serodiscordant couples were identified as a hindrance to having children, matching with the evidence that exposed the dilemma women experience facing the risk of contamination from the conceptus and their partners (26) .Thus, counseling on reproduction is the recommendation for the couple, aimed at choosing the right time for conception, including discussion of other specific options for preventing HIV transmission, such as sperm washing and assisted reproduction.
Usage time of ART was also a predictor for women to bear children while infected with HIV, possibly because antiretrovirals promote improvement in health status and survival rate, factors that may favor maternity and reduce the risk of vertical transmission (25) .However, it was found that there was no link between the desire to have children and the length of time of using ART, in opposition to the speculations that indicate the increase in the wish to have children as the ART progresses (25) .

CONCLUSION
Knowledge of positive anti-HIV serology predominated during the prenatal period and the rejection of the wish to have more children.Age less than 39 years, higher educational level, and less ART time increased the chances of women with AIDS having already had children.Furthermore, women under 39 years of age and with a higher educational level had better chances of obtaining the right information on the possibility of having children while living with HIV.Having a steady relationship increased the chance of wishing to have children, while tubal ligation was high in women that did not receive counseling on family planning.
Despite the fact that Brazil has a policy on prevention of vertical transmission of HIV, efforts made to provide the means to increase the dialogue on family planning during outpatient care of Brazilian women with AIDS are critical to minimize the myths and provide conscious and safe decisions on reproductive choices.It is also necessary to guarantee access to contraceptive methods to all who wish to use them.Initiatives for this effect have an impact on improving knowledge, and on the attitudes and behavior regarding contraception for this target group.
The limitation of this study is represented by data collection in a single moment, and it was not possible to identify probable changes in behavior after the follow-up, including a lack of detail regarding the reasons for not using contraceptive methods.Despite this limitation, it is worth highlighting the importance of this study, taking into account that oftentimes the reproductive aspects and contraception methods for women with HIV/AIDS are not a priority during outpatient care, due to the stigma that surrounds the disease.As a consequence, the importance of new studies from the perspective of following up women with AIDS, and interventions oriented in this context, is emphasized.

Table 2 -
Reproductive background and contraceptive use of 102 women living with AIDS -Fortaleza, Ceará, Brazil, Jan./Dec.2015 *Those with an affective-sexual relationship for at least three months.continued… …continuation

Table 3 -
Knowledge of family planning of 102 women living with AIDS -Fortaleza, Ceará, Brazil, Jan./Dec.

2015 Knowledge of family planning n (%) Did receive counseling on family planning while living with HIV?
*Serodiscordant: partner with negative anti-HIV serology; †Seroconcordant: partner with positive anti-HIV serology

Table 4 -
Reproductive background and contraceptive methods associated with the desire to have children of 102 women living with AIDS -Fortaleza, Ceará, Brazil, Jan./Dec.2015.

Table 5 -
Socio-demographic and clinical aspects associated with the reproductive background, use of contraceptive and knowledge of family planning among 102 women living with AIDS -Fortaleza, Ceará, Brazil, Jan./Dec.