J. Biosoc. Sci., (2014) 46, 580-599, © Cambridge University Press, 2013 
doi: 10.1017/S0021932013000655 First published online 16 Dec 2013
DOES K N O W L E D G E  ABOUT A N T I ­
R E T R O V I R A L  T H E R A P Y  AND MO T H E R - T O -  
C H I L D  T R A NS MI S S I ON A F F E C T  THE 
R E L A T I O N S H I P S  BETWEEN HIV STATUS 
A N D  F E R T I L I T Y  P R E F E R E N C E S  AND 
C O N T R A C E P T I V E  USE? NEW E VI D E NC E  
F R O M  N I G E R I A  AND ZAMBI A
AKINRINOLA BANKOLE*1, ANN E. BIDDLECOMj, 
KUMBUTSO DZEKEDZEKEj, JOSHUA O. AKINYEMI§, 
OLUTOSIN AWOLUDE§ and ISAAC F, ADEWOLE§
*Guttmacher Institute, New York, USA, ^Population Division, United Nations, 
New York, USA, \Independent Consultant, Lusaka, Zambia and §University o f Ibadan
Ibadan, Nigeria
Summary. The increasing availability of antiretroviral therapy (ART) and 
drug regimens to prevent mother-to-child transmission (PMTCT) has probably 
changed the context of childbearing for people living with HIV. Using data 
from 2009-2010 community-based surveys in Nigeria and Zambia, this study 
explores whether women’s knowledge about ART and PMTCT influences the 
relationship between HIV status and fertility preferences and contraceptive 
behaviour. The findings show that women living with HIV are more likely to 
want more children in Nigeria and to want to limit childbearing in Zambia 
compared with HIV-negative women. While there is no significant difference 
in contraceptive use by women’s HIV status in the two countries, women who 
did not know their HIV status are less likely to use contraceptives relative to 
women who are HIV-negative. Knowledge about ART reduces the childbear­
ing desires of HIV-positive women in Nigeria and knowledge about PMTCT 
increases desire for more children among HIY-positive women in Zambia, as 
well as contraceptive use among women who do not know their HIV status. 
The findings indicate that knowledge about HIV prevention and treatment 
services changes how living with HIV affects childbearing desires and, at least 
in Zambia, pregnancy prevention, and highlight the importance of access to 
accurate knowledge about ART and PMTCT services to assist women and 
men to make informed childbearing decisions. Knowledge about ART and 
PMTCT should be promoted not only through HIV treatment and maternal 
and newborn care facilities but also through family planning centres and the 
mass media.
1 Corresponding author. Email: abankole@guttmacher.org
580
A R T  and PM TCT knowledge, H IV  status and fertility 581
introduction
The increasing availability of HIV-related prevention and treatment services in sub- 
Saharan Africa, the region currently accounting for approximately 70% of people 
living with HIV in 2012 (UNAIDS, 2013), introduces new questions about how HIV 
affects people’s childbearing desires and pregnancy prevention behaviour. The ex­
panded coverage of antiretroviral therapy (ART) and drug regimens for the prevention 
of mother-to-child transmission of HIV (PMTCT) have offered people living with HIV 
hope for a longer, healthier life and dramatically increased the chances that they can bear 
children who are free of the virus. In 2012, an estimated 68% of adults in sub-Saharan 
Africa in need of ART were receiving it, although coverage is uneven with West and 
Central Africa tending to report lower ART coverage than East and Southern Africa 
(UNAIDS, 2013). In the same year, an estimated 64% of pregnant women living 
with HIV received antiretrovirals to prevent transmission of HIV to their children 
(UNAIDS, 2013). While ART and PMTCT coverage must still progress further in 
sub-Saharan Africa, childbearing and family planning decisions in the context of the 
AIDS epidemic are potentially very different in the region now than just a decade ago. 
This study contributes new community-based evidence on whether and how knowledge 
about ART and PMTCT changes the association between HIV status and fertility 
preferences and contraceptive use in two sub-Saharan African countries with different 
levels of PIIV prevalence and ART and PMTCT coverage.
Arguments about how living with HIV influences childbearing desires and pregnancy 
prevention in countries with generalized AIDS epidemics, in the absence of widespread 
coverage of ART and PMTCT, have been in opposite directions (Rutenberg et al., 2000; 
United Nations, 2002). The actuality or perception of being HIV-positive could lead 
people to want to stop childbearing because of the uncertainty about how long they 
will live to be able to take care of their children, worry about who will take care of their 
orphaned children after they die, fear that newborn children will be infected or concerns 
that pregnancy may negatively affect the mother’s health. Social and cultural factors, 
particularly the pressures of family members or the need to continue the family lineage, 
also play a critical role in how HIV shapes childbearing decisions (Nattabi et al., 2009).
Recent cross-sectional and longitudinal evidence from different sub-Saharan African 
countries generally supports a positive association of living with HIV and a desire to 
stop childbearing, although these positive associations do not apply across all countries 
(Johnson et al. 2009; Bankole et al. 2011). Longitudinal data from a clinical trial in 
Malawi showed that HIV-positive women were about three times more likely to change 
from wanting more children to wanting no more children over a 12-month period com­
pared with HIV-negative women and more than half as likely to change from wanting 
no more children to continue childbearing. Despite these divergent fertility desires, 
pregnancy rates were comparable among both groups over the 12-month follow-up 
period (Taulo et al., 2009). The positive association between living with HIV and 
lowered childbearing intentions is also dependent on being part of a sero-discordant 
couple (Bonnenfant et al., 2012).
Data from a mixed-method, longitudinal study in rural Malawi that focused explic­
itly on fertility preferences and HIV status, and where ART and PMTCT were just 
being introduced, found that fewer men and women desired to have more children
582 A. Bankole et al.
following their receipt of a positive HIV test result, and the main rationale for the 
change in continued childbearing differed by gender: men tended to focus on their pre­
mature death and longer-term consequences for the care of their children while women 
tended to focus on the health consequences in the short-term of pregnancy and child­
birth (Yeatman, 2009). Moreover, the impact on fertility preferences was weaker among 
women than men, and the qualitative data suggested a continued strong role of social 
pressures on women for continued childbearing. Evidence from a rural Mozambique 
setting provides even further nuance to these arguments by showing that women and 
men who perceive themselves as probably being HIV-positive -  a relevant indicator 
given that many people have not received a test and are making reproductive decisions 
in a context of uncertainty about their status -  are not only more likely to want to stop 
childbearing (versus wanting a birth later) but also more likely to want to have a child 
soon (Hayford et al., 2012). The study authors argue that the association of being HIV­
positive with intentions of ‘limiting or accelerating’ childbearing reflects a balanced 
calculus of the health concerns, premature death and uncertainty associated with being 
HIV-positive and the strong desires for childbearing in a high-fertility setting. A similar 
finding of preferences for having a child sooner rather than later was observed among 
young adults in Malawi who were uncertain about their HIV status compared with 
young adults who were certain that they were HIV-negative (Trinitapoli & Yeatman, 
2011).
As with fertility desires and intentions, arguments about how HIV status influences 
contraceptive use for pregnancy prevention have also been in both directions: being 
HIV-positive could make one more likely to use contraceptives because of an increased 
motivation to avoid further childbearing, or less likely to use contraceptives because of 
concerns about health side-effects of methods, especially if one’s health is already com­
promised from HIV. Studies from sub-Saharan African countries generally show a 
positive association between women’s actual or probable knowledge of their HIV­
positive status and using contraception, especially condoms (Elul et al., 2009; Johnson 
et al, 2009; Bankole et al., 2011; Maharaj et al., 2011).
The increased availability of ART and PMTCT has added a further level of 
complexity to these associations. Qualitative research from Cape Town, South Africa, 
suggests that ART and PMTCT have motivated women and men living with HIV to 
reconsider their childbearing desires towards having (more) children precisely for 
health-related reasons: the increased chances that the children they bear will not be 
infected with HIV and because of their own improved health (Cooper et al., 2007).
Health facility-based studies that focus on women receiving ART and PMTCT pro­
vide some support for these qualitative findings, though again not always consistently. 
A study involving women enrolled in an PIIV care and treatment programme in seven 
sub-Saharan African countries found that women receiving ART had a significantly 
higher pregnancy rate than HIV-positive women who were not yet receiving ART and 
the risk of pregnancy increased the longer a woman was on ART, though the study 
could not discern if fertility desires were different or if the pregnancies were intended 
(Myer et al., 2010). A study of women in Uganda had similar findings of a higher preg­
nancy rate among HIV-positive women on ART compared with HIV-positive women 
who had not yet initiated ART, and the desire for more children played an important 
role in explaining these differences (Makumbi et al., 2011). A cross-sectional study of
A R T  and PM TCT knowledge, HIV status and fertility 583
HIV-positive patients attending an ART service facility in South Africa found that 
women’s desire to have children increased with duration of ART treatment (Myer 
et al., 2007) and a two-year prospective cohort study in Uganda of women who had 
recently initiated ART found an increase in pregnancy incidence over time, though 
not all women wanted to become pregnant (less than 7% of women reported wanting 
more children compared with 14% of women who became pregnant during the study 
period, and 26 of the 140 pregnancies ended in an induced abortion; Homsy et al., 
2009).
The small but growing literature on how ART and PMTCT change the relationship 
between living with HIV and using contraception also shows some supportive findings. 
Two cross-sectional studies of women attending an HIV clinic in Uganda found 
greater fertility desire among women receiving ART compared with those who were 
not (Maier et al., 2009) and greater use of contraception, especially barrier methods, 
among women receiving ART compared with those who were not (Andia et al,
2009) . Among women recruited from a perinatal HIV research unit in South Africa, 
there was no statistically significant difference in contraceptive use (either any method 
or barrier methods) among HIV-positive women by ART use, though women on ART 
were more likely to use contraceptives than HIV-negative women (Kaida et al., 2010). 
A study of condom use among women receiving ART at a teaching hospital in Nigeria 
showed that the longer women received ART-related services, the higher the prevalence 
of condom use, and this was especially the case for married women (Akinyemi et al.,
2010) . Of course, the use of barrier methods of contraception could be for preventing 
HIV transmission among partners in addition to, or instead of, pregnancy prevention 
purposes.
This study builds on the evidence from community-based studies on HIV status (or 
perceived status) and fertility preferences and contraceptive use as well as facility-based 
studies on the impact of ART and PMTCT on reproductive behaviours by drawing 
on community-based data that explicitly factor in people’s awareness of ART and 
PMTCT and their perceptions of effectiveness. Data for the study come from Nigeria 
and Zambia, two countries from the western and southern sub-regions of sub-Saharan 
Africa, respectively, chosen for their different HIV, fertility preference and abortion 
contexts, as well as ART and PMTCT coverage. In Nigeria in 2009, when the study 
was designed, desired family size was 6.1 children and contraceptive prevalence was 
14.6% among married or in-union women of reproductive age and 61.0% among 
unmarried, sexually active women (National Population Commission & ICF Macro, 
2009). In 2012, HIV prevalence among adults was 3.1% in Nigeria, 36% of adults 
who needed ART were receiving it and just 17% of pregnant women with HIV received 
antiretrovirals to prevent MTCT (UNAIDS 2013).
In Zambia, in 2009, mean desired fertility was 4.6 children and contraceptive 
prevalence was 40.8% among married or in-union women of reproductive age and 
47.5% among unmarried, sexually active women (Central Statistical Office et al., 
2009). In 2012, HIV prevalence among adults in Zambia was 12.7% (UNAIDS, 2013). 
Antiretroviral therapy and PMTCT coverage were also much higher than in Nigeria: 
86% of adults in need of ART were receiving it in 2012 and 95% of pregnant women 
with HIV were receiving a prophylaxis to prevent the transmission of HIV from mothers 
to their babies (UNAIDS, 2013).
584 A. Bankole et al.
Although the two countries have different levels of HIV prevalence, they are home 
to two of the largest HIV-positive populations in sub-Saharan Africa. They provide 
contrasting contexts within which to examine how knowledge about ART and 
PMTCT may interact with the association between HIV status and fertility preference 
and contraceptive behaviour. Much of the existing research evidence is based on 
studies of people living with HIV and receiving ART or HIV-positive women who 
have received PMTCT, yet the fact remains that many women of reproductive age in 
sub-Saharan African countries still do not know their HIV status or, if they know they 
are HIV-positive, many lack access to ART or PMTCT, if needed (Mishra et al. , 2009; 
UNAIDS, 2013). A contribution of this study is its use of community-based survey 
data to reflect people’s uncertain knowledge of their HIV status and actual knowledge 
about ART and PMTCT.
D ata and Methods
Data for this study come from 2009-2010 household-based surveys in Nigeria and 
Zambia, which were part of a larger study of how women and men achieve their repro­
ductive goals while living with or trying to prevent HIV. The surveys were conducted 
in three provinces in Zambia (Lusaka, Northern and Southern) and four states in 
Nigeria (Kaduna, Benue, Lagos and Enugu) to ensure that data were gathered from 
different parts of the country and from regions with varying PIIV prevalence and 
fertility levels. The surveys are national in scope though not nationally representative. 
The study protocols were approved by the Institutional Review Board (IRB) of the 
Guttmacher Institute, the IRB of the University of Ibadan/University College Hospital 
in Nigeria and the University of Zambia Biomedical Research Ethics Committee.
To conduct the survey in Nigeria, one rural and one urban Local Government Area 
(LGA) were randomly selected from each of the four selected states. The target sample 
size was proportionately allocated to the LGAs based on the 2006 Nigeria population 
census figures. The number of Enumeration Areas (EAs) sampled in each LGA was 
based on the sample allocated to the LGA. Ten and 20 EAs were then systematically 
selected from the rural and urban LGAs, respectively. In the selected EA, 10% of 
households were systematically selected for interview.
The Zambia survey sample was based on the sample frame from the 2007 Zambia 
Demographic and Health Survey (DHS). The number of households selected was 
determined by the ratio of households to completed interviews of the population 15 
years and older observed in the 2007 DHS. In order to yield the target sample size, 60 
Enumeration Areas (EAs) were selected by equal probability systematic sampling, 
including 38 rural and 22 urban EAs. The total sample was allocated to the provinces 
proportional to its projected population of 2009 distributed by urban and rural areas, 
which was obtained from the Central Statistical Office.
In both countries, all eligible adults (women aged 18-49 and men aged 18-59) in 
selected households were interviewed by trained interviewers from the same province 
or state as the respondents. A total of 2451 reproductive-age adults (1256 women and 
1195 men) in Nigeria and 2400 (1280 women and 1120 men) in Zambia were success­
fully interviewed. The response rates were 94.3% and 92.4% in Nigeria and Zambia,
A R T and PM TCT knowledge, H IV status and fertility 585
respectively. Data collection lasted from November 2009 to May 2010 in Nigeria and 
from October 2009 to February 2010 in Zambia.
Outcome variables
Two outcome variables were examined. The first was ‘desire for a/another birth’, 
which was obtained from responses to a DHS-type question ‘Would you like to have 
a/another child, or would you prefer not to have any (more) children?’ (If pregnant, 
the question was prefaced by ‘After this pregnancy . . . ’) and was defined as a two- 
category variable taking on the value of 1 if the respondent wanted more children and
0 otherwise. Those who said they were unsure were treated as wanting more.
The second outcome variable (current use of any method) was measured from 
survey responses to another DFIS-type question ‘Are you currently doing something 
or using any method to delay or avoid getting pregnant?’ This variable was defined as
1 if a married person or an unmarried individual who was sexually active (i.e. had had 
sex in the 3 months prior to the survey) responded affirmatively to the question, other­
wise it assumed the value of 0.
H IV status
HIV status, the key independent variable, was based on self-reports of status from a 
series of survey questions beginning with ‘Have you ever been tested to see if you have 
the AIDS virus?’ Those who said ‘yes’ were asked follow-up questions, including ‘How 
long ago were you last tested for the AIDS virus?’ and ‘Did you get the results of that 
test?’ Those who responded affirmatively to this last question were then asked ‘Would 
you tell me your HIV test results?’ with an interviewer instruction to say ‘Please know 
that I will keep this information confidential’. In addition, because stigma associated 
with being HIV-positive may prevent an HIV-positive person reporting her/his status 
in a face-to-face interview, a sealed-envelope module was added to the survey. In this 
module, which was fielded at the end of the face-to-face interview, the respondent was 
able to respond to questions on several sensitive issues, including HIV status, in confi­
dence by marking their responses on a sheet of paper, putting the paper in an envelope 
and sealing it before handing it over to the interviewer. From the responses to ques­
tions on HIV status in both of these approaches, the HIV status variable was created 
with the following three categories: (1) HIV-positive; (2) HIV-negative; (3) FIIV status 
unknown. Women who reported being HIV-positive in either the face-to-face interview 
or the sealed-envelope module were coded as being HIV-positive.
Knowledge about HIV-treatment variables
The variables considered in this paper were (1) knowledge about antiretroviral 
(ARV) drugs and (2) knowledge about prevention of mother-to-child transmission 
drugs. Each of these variables was constructed from respondents’ answers to two ques­
tions on the respondents’ awareness of the existence of a drug for this purpose and 
what they think about the efficacy of the drug.
586 A. Bankole et al.
Knowledge about A R V  drugs. Each respondent who had heard of HIV was asked 
‘Have you heard about special antiretroviral drugs (USE LOCAL NAME) that people 
infected with the AIDS virus can get from a doctor or nurse to help them live longer?’ 
Those who said ‘yes’ to this question were asked a series of follow-up questions includ­
ing, ‘Do you know of any place that gives these drugs to people with the virus that 
causes AIDS?’ and ‘Do you think that these drugs work all of the time, some of the 
time or none of the time?’ Responses to the first and the last question indicated above 
were used to create the knowledge about ART variable with two categories: (1) know a 
drug, works at least some of the tune; (2) know a drug, does not work/know no drug.
Knowledge about PM TCT drugs. The knowledge about PMTCT drugs variable was 
similarly created based on direct responses to questions in the survey that reflect both 
the respondents’ awareness of a drug for PMTCT and their perception of its efficacy. 
The respondent was asked ‘Are there any special drugs that a doctor or nurse can give 
to a woman infected with the AIDS virus to reduce the risk of transmission to the 
baby?’ Those who answered ‘yes’ were then asked the following question ‘Do you think 
that these drugs prevent the baby from getting the virus that causes AIDS all of the 
time, some of the time or none of the time?’ As was done in the case of knowledge 
about ART, the responses to this and the penultimate question (above) were used to 
construct the ‘knowledge about PMTCT’ valuable with the following two categories: 
(1) know'a drug, works at least some of the time; (2) know a drug, does not work/ 
know no drug. For survey questions about ART and PMTCT drugs, some of the 
respondents are likely to be incorrect in their assessment of the efficacy of the drugs, 
but respondent assessments (whether factually correct or not) were used since what 
affects their reproductive behaviour is their perception of the efficacy of the drugs 
rather than how correct they are in their understanding of actual drug efficacy.
Other demographic and socioeconomic variables included in the models were age, 
rural-urban residence, education, number of living children, union status and religion. 
These covariates were selected because they have been shown in the literature reviewed 
to be correlated with desire for more children and current contraceptive use. All 
covariates were used as categorical variables in the analysis and were measured at the 
time of the survey.
The multivariate analysis is based on a set of logistic regression models. First, a 
regression equation was fitted modelling the association between HIV status and the 
outcome variables, controlling for the effects of women’s background characteristics 
(i.e. age, residence, education, union status, number of living children and religion) 
(Model 1, Tables 3 and 4). Second, knowledge about ARV drugs and the interaction 
between HIV status and knowledge about ARV drugs were added to Model 1 (Model 
2, Tables 3 and 4). The results from this model determine whether knowledge about 
ARV drugs has a direct association with the outcome variable and whether it has an 
impact on the association between HIV status and the outcome variables. A significant 
interaction between HIV status and knowledge about ARV drugs implies that knowl­
edge about ART has some influence on the association between HIV status and the 
outcome variable. Third, knowledge about PMTCT drugs and the interaction between 
HIV status and knowledge about PMTCT drugs were added to Model 2 in order to 
assess the direct effect on the outcome variables as well as the influence of knowledge
A R T  and PM TCT knowledge, H IV  status and fertility 587
about PMTCT drugs on the association between HIV status and the outcome variables 
(Model 3, Tables 3 and 4). Finally, a model including all variables in Model 1 plus 
knowledge about ARV drugs and PMTCT drugs and their interactions with HIV 
status was run (Model 4, Tables 3 and 4). The objective was to examine whether 
knowledge about ARV drugs and knowledge about PMTCT drugs simultaneously affect 
the association between HIV status and the outcome variables.
Since Model 1 is nested under each of the other three models (Models 2 to 4), 
whether each of the successive models has a better fit compared with the parsimonious 
Model 1 was examined. The adjusted Wald test was used to examine whether inclusion 
of the additional parameters in Models 2 to 4 contributes significantly to the fit of 
Model 1. All estimates presented in this paper are weighted national estimates. For 
the regression results, statistical significance is indicated at the 0.10, 0.05 and 0.01 
levels, using two-tailed tests. The standard errors of the estimates were computed using 
the ‘svy’ procedure in STATA 12 to account for the complex sample designs (Stata 
Corporation, 2007).
Results
Background characteristics o f respondents
The socio-demographic profiles of the respondents are presented in Table 1. The 
age distributions of respondents in Nigeria and Zambia are generally similar, though 
the sample was somewhat younger in Nigeria than in Zambia (39% versus 32% were 
18-24 years old in Nigeria and Zambia, respectively). In both countries the majority 
of women (54%) lived in rural areas. The education profiles are quite different: 26% of 
Nigerian women had no education compared with 9% of their Zambian counterparts, 
yet 54% of Nigerian women had attended school at secondary or higher level com­
pared with 41% of women in Zambia. Most adult women were married or in a union: 
60% in Nigeria and 66% in Zambia. The distribution of the number of living children 
among women tends towards lower numbers in Nigeria (e.g. 50% of women have 0-1 
living children compared with 32% of women in Zambia), though this may be due in 
part to the younger age distribution of women in Nigeria compared with women in 
Zambia. The vast majority of the sampled women in each country identified as Catholic, 
Protestant or Pentecostal (66% in Nigeria and 90% in Zambia). Again, the surveys were 
national in scope but not nationally representative, so the sample characteristics are not 
generalizable to the country level.
H IV  status, knowledge about A R V  drugs and knowledge about PM TCT drugs
Table 2 shows the percentage distribution of women by their reported HIV status, 
knowledge about ARV drugs and knowledge about PMTCT drugs, by country.
H IV  status. About 2% of women in Nigeria and 6% in Zambia reported themselves 
as PHV-positive, 21% in Nigeria and 52% in Zambia said they were PHV-negative and 
the rest did not know their status. Because of the stigma associated with HIV in sub- 
Saharan Africa, HIV-positive status is expected to be under-stated in self-reports.
588 A. Bankole et al.
Table 1. Percentage distribution of female respondents by socio-demographic 
characteristics, Nigeria and Zambia, 2009-2010
Nigeria Zambia
Age
18-24 39.0 31.9
25-34 33.7 36.7
35-49 27.4 31.4
Residence
Urban 46.2 45.8
Rural 53.8 54.2
Highest level of school attended
None 26.4 9.3
Primary 19.9 49.5
Secondary or higher 53.7 41.2
Union status
In union 59.9 66.2
Not in union 40.2 33.8
Number of living children
0-1 49.9 32.3
2-3 24.6 31.2
4-5 13.8 19.3
6 or more 11.7 17.2
Religion
Catholic 31.3 25.1
Protestant 21.8 50.9
Pentecostal 13.2 14.2
Others 33.7 9.8
No. of cases 1,119 1,268
Total % 100.0 100.00
Thus, while only 2% of women in the Nigeria sample and 6% in the Zambia sample 
reported being HIV-positive, the prevalence rates among adults in the two countries 
were 3.1% for Nigeria and 12.7% for Zambia (UNAIDS, 2013). While the difference 
between these estimates may be partly due to the fact that the study is not nationally 
representative, self-reports of status in the study, including reports from the confiden­
tial sealed-envelope method, as compared with findings from biomarker HIV tests 
account for some of the difference. Another reason for the gap is because many people 
had not received an HIV test (or obtained their results) and therefore did not know 
their status.
Knowledge about ARV drugs. The majority of Nigerian women (53%) and almost 
all Zambian women (94%) reported that they knew of antiretroviral drugs and believed 
that they work at least some of the time. Forty-seven per cent of women in Nigeria and 
only 6% in Zambia indicated that they did not know of ARV drugs or knew of them 
but believed that they were not effective. The substantially higher percentage of women 
in Zambia than in Nigeria who knew of ARV drugs and believed that they were effec-
A R T  and PM TCT knowledge, H IV  status and fertility 589
Table 2. Percentage distribution of female respondents by HIV status, knowledge of 
ARV and PMTCT drugs, desire for more children and contraceptive use, Nigeria and
Zambia, 2009-2010
Nigeria Zambia
HIV status
HIV-positive 1.7 5.8
HIV-negative 21.4 52.0
Don’t know 76.9 42.1
Knowledge of ARV drugs
Know a drug, effective at least some of the time 53.1 93.8
Know a drug, not effective/know no drug 46.9 6.2
Knowledge of PMTCT drugs
Know a drug, effective at least some of the time 58.4 75.9
Know a drug, not effective/know no drug 41.6 24.1
Desire for more children
Want more 81.4 63.5
Want no more 18.7 36.5
Current use of contraception
Using 15.3 34.6
Not using 84.7 65.5
No. of cases 1119 1268
Total % 100.0 100.0
tive is probably a reflection of the greater coverage of ARV in Zambia than in Nigeria 
(in 2012, 86% of adults who needed ARV drugs received them in Zambia compared 
with 36% of adults in Nigeria) (UNAIDS, 2013)
Knowledge about PM TCT drugs. With respect to drugs for preventing mother-to- 
child transmission of HIV, 58% of women in Nigeria and 76% of women in Zambia 
knew of PMTCT drugs and believed that they work at least some of the time. As in 
the case of ARV drugs, knowledge about PMTCT drugs is more pervasive in Zambia 
than in Nigeria, and this difference is probably associated with higher levels of access 
to PMTCT for pregnant Zambian women compared with pregnant women in Nigeria. 
As noted earlier, while more than 95% of pregnant women with HIV received antiretro­
virals to prevent MTCT in Zambia, the percentage was just 17% in Nigeria (UNAIDS, 
2013).
Desire to limit childbearing and contraceptive use
Nineteen per cent of women in Nigeria compared with 37% of women in Zambia 
wanted to stop childbearing. Similarly, while only 15% of Nigerian women were 
currently using a method of family planning, 35% of their Zambian counterparts were 
doing so. The difference between the two countries in terms of the levels of desire and 
motivation of women in this study to limit family size is not surprising. As noted in the 
Introduction, both the wanted and actual fertility rates are lower in Zambia compared
590 A. Banlcole et al.
with Nigeria and contraceptive prevalence is higher in Zambia than in Nigeria. More­
over, the age distribution of this sample was younger and the number of living children 
lower in Nigeria than in Zambia, which would explain in part the smaller percentage of 
women who wanted to stop childbearing in Nigeria compared with Zambia.
H IV  status, knowledge about A RV  and PM TCT drugs and desire for more children
Table 3 presents the odds ratios from logistic regression models of the association 
between HIV status, knowledge about ARV and PMTCT drugs and desire for more 
children when controlling for women’s socio-demographic background characteristics. 
In Nigeria, there is no significant association between HIV status and desire for more 
children, net of women’s background characteristics (Table 3, Model 1, Column 1). 
In fact, the model does not constitute an improvement over the parsimonious model 
(not shown), which includes only the women’s background characteristics (p — 0.582). 
When knowledge about ARV drugs and its interaction with HIV status were added 
to the model, HIV status emerged as an important predictor of desire for additional 
children. HIV-positive women who did not know about ARV drugs or believe that 
they are effective were about two and a half times more likely to desire more children 
than HIV-negative women who did not know about ARV drugs or believe that they 
work (Table 3, Model 2, Column 2). Knowledge about ARV drugs does not show an 
independent association with desire for more children. However, it interacts with HIV 
status to produce a significant association with desire for more children. PHV-positive 
Nigerian women who knew of ARV drugs and believed that they worked at least some 
of the tune were about 80% less likely to desire more children than HIV-positive women 
who were not aware of any ARV drug or did not believe that such drugs were effective.
When knowledge about PMTCT drugs and its interaction with HIV status were 
added to Model 1 neither HIV status nor knowledge about PMTCT drugs emerged as 
a significant predictor of desire for more children among women in Nigeria (Table 3, 
Model 3, Column 3). Similarly, when knowledge about ARV drugs and knowledge 
about PMTCT drugs and their interactions with HIV status were added to Model 1, 
none of the two variables emerged as a significant predictor of desire for more children 
(Table 3, Model 4, Column 4). Consequently, since Model 2 is the most parsimonious, 
it provides the best fit for the Nigeria data and it is concluded that knowledge about 
ARV drugs exerts a significant effect on the association between HIV status and desire 
for more children among Nigerian women.
In Zambia, HIV status emerged as an important determinant of desire for more 
children among women, net of background characteristics (Table 3, Model 1, Column 
5). Women who were HIV-positive were about 60% less likely than PIIV-negative 
women to desire more children. This difference is marginally significant (at 10% level). 
Women who did not know their HIV status were about 40% more likely to want more 
children compared with their HIV-negative counterparts. The inclusion of the HIV status 
variable in a model with only the women’s background characteristics significantly im­
proved the fit of the model (p = 0.004). Neither knowledge about ARV drugs nor its 
interaction with HIV status emerged as significant predictors of desire for more children 
when these variables were added to Model 1 (Table 3, Model 2, Column 6). Although
Table 3. Odds ratios of the effects of HIV status, knowledge of ARV drugs and knowledge of PMTCT drugs on desire for more
children, Nigeria and Zambia, 2009-2010
Nigeria Zambia
Explanatory variable Model 1 Model 2 Model 3 Model 4 Model 1 Model 2 Model 3 Model 4
HIV status
HIV-positive 0.793 3.696*** 1.011 3.922 0.393* 0.279 0.044*** 0.022***
HIV-negative (Ref.) 
Don’t know 0.815 0.517 1.068 0.734 1.380** 1.783** 1.047 1.311
Knowledge of ARV drugs
Know a drug, effective at least some of the time 0.612 0.522 0.700 0.641
Know a drug, not effective/know no drug (Ref.)
HIV status x Knowledge of ARV drugs
HIV-positive x Know a drug, effective at least 0.192** 0.230** 1.519 2.088
some of the time
Don’t know HIV status x Know a drug, effective 2.262 2.884 0.683 0.608
at least some of the time
Knowledge of PMTCT drugs
Know a drug, effective at least some of the time 1.380 1.677 0.928 0.969
Know a drug, not effective/know no drug (Ref.)
HIV status x Knowledge of PMTCT drugs
HIV-positive x Know a drug, effective at least some 0.710 0.747 10.944** 12.214**
of the time
Don’t know HIV status x Know a drug, effective at 0.675 0.475 1.446 1.707
least some of the time
Adjusted Wald test (Prob > F) 0.582 0.040 0.870 0.118 0.004 0.167 0.098 0.020
No of cases 1114 1114 1114 1114 1268 1268 1268 1268
Ref. =  reference category. N  values are unweighted.
The socioeconomic variables included in Models 1 to Model 3 are age, residence, number ofliving children, education, union status, children 
and religion (results not shown).
*p <0.1; **p <  0.05; ***p <0.01.
L /l
VO
A R T  and P M T C T  knowledge, H IV  status and fertility
592 A. Banlcole et al.
the inclusion of the two variables eliminated the marginal difference between HIV- 
positive and HIV-negative women with respect to their desire for more children, the 
significant difference between the desires of HIV-negative women and those who did 
not know their status remained unchanged. Consequently, Model 2 is the preferred 
model for Zambia.
The inclusion of knowledge about PMTCT drugs and its interaction with HIV status 
shows that knowledge about PMTCT drugs exerts a significant impact on the association 
between PIIV status and desire for more children (Table 3, Model 3, Column 7). HIV­
positive women who did not know a PMTCT drug or believed it works are about 96% 
less likely to desire more children than HIV-negative women with the same knowledge 
about PMTCT drugs. There is no difference between the desires of HIV-negative 
women who did not know about PMTCT drugs or believe that they work and those of 
their counterparts who did not know their PIIV status. Furthermore, HIV-positive 
women who knew about a PMTCT drug and believe that it works at least some of 
the time are about 10 times more likely to desire more children compared with HIV­
positive women who did not know of a PMTCT drug or believe that such drugs are 
effective. The inclusion of knowledge about PMTCT drugs and its interaction with 
HIV status does provide marginal improvement of the fit of the model compared with 
Model 1 (p = 0.098). Finally, when knowledge about ARV drugs and knowledge about 
PMTCT drugs, as well as their interactions with HIV status, were added to Model 1, 
the results remained quite similar to the results in Model 3 (Table 3 Model 4, Column 
8). HIV-positive women who did not know about ARV and PMTCT drugs or believe 
that they are effective were about 98% less likely to desire more children than HIV­
negative women who did not know about ARV and PMTCT drugs or believe that 
they work. When an HIV-positive woman knows about a PMTCT drug that works at 
least some of the time, she is about 11 times more likely to desire more children com­
pared with a HIV-positive woman who does not. Since Model 4 is more superior to 
Model 1 than Model 3, Model 4 was adopted as the preferred model for Zambia and 
it is concluded that knowledge about PMTCT drugs influences the association between 
HIV status and desire for more children among Zambian women.
H IV  status, knowledge about A R V  and PM TCT drugs and current use o f  contraception
Table 4 presents the results of the logistic regression models of the relationship 
between HIV status, knowledge about ARV and PMTCT drugs and current use of 
contraception among sexually active women in Nigeria and Zambia. For Nigeria, 
HIV status emerged as a significant predictor of current use of contraception, net of 
women’s background characteristics (Table 4, Model 1, Column 1). Women who did 
not know their status were about 54% less likely to be using a method than HIV­
negative women. While HIV-positive women tend to be less likely to use a method 
than HIV-negative women, the difference is not statistically significant. Overall, this 
model is superior to the model (not shown) that includes only women’s characteristics 
(p = 0.002). When knowledge about ARV drugs and its interaction with HIV status 
were added to Model 1, the results indicate that knowledge about ARV drugs shows a 
significant association with current use of contraception (Table 4, Model 2, Column 2). 
HIV-negative women who knew of ARV drugs and believed they worked at least some
Table 4. Odds ratios of the effects of HIV status, knowledge of ARV drugs and knowledge of PMTCT drugs on current
contraceptive use, Nigeria and Zambia, 2009-2010
Nigeria Zambia
Explanatory variable Model 1 Model 2 Model 3 Model 4 Model 1 Model 2 Model 3 Model 4
HIV status
HIV-positive 0.541 0.970 0.904 1.220 0.770 0.345 0.218 0.069**
HIV-negative (Ref.) 
Don’t know 0.461*** 0.740 0.648 0.855 0.579*** 0.679 0.318*** 0.381***
Knowledge of ARV drugs
Know a drug, effective at least some of the time 2.806** 2.750** 1.521 1.578
Know a drug, not effective/know no drug (Ref.)
HIV status x Knowledge of ARV drugs
HIV-positive x Know a drug, effective at least some 0.445 0.699 2.698 3.070
of the time
Don’t know HIV status x Know a drug, effective at least 0.594 0.688 0.838 0.806
some of the time
Knowledge of PMTCT drugs
Know a drug, effective at least some of the time 1.455 1.051 0.567** 0.550**
Know a drug, not effective/know no drug (Ref.)
HIV status x Knowledge of PMTCT drugs
HIV-positive x Know a drug, effective at least some 0.482 0.434 4.162 5.483
of the time
Don’t know HIV status* Know a drug, effective at least 0.621 0.680 2.086** 2.098**
some of the time
Adjusted Wald test (Prob > F) 0.001 0.148 0.576 0.386 0.005 0.387 0.073 0.234
No. of cases 772 772 772 772 976 976 976 976
Ref. =  reference category. N  values are unweighted.
The socioeconomic variables included in Models 1 to Model 3 are age, residence, number of living children, education, union status, children 
and religion (results not shown).
*p < 0.1; **p <  0.05; ***p < 0.01.
U h
VD
LO
A R T and PM TCT knowledge, HIV status and fertility
594 A. Bankole et al.
of tie  time were almost three times as likely to use contraception as HIV-negative 
women who did not know of ARV drugs or believe that they are effective. The inclu­
sion of these variables eliminated the significant difference between the contraceptive 
use of HIV-negative women and women who did not know their status. However, 
Model 2 does not constitute an improvement over Model 1 (p = 0.148), so the findings 
from the parsimonious Model 1 are preferred.
The results of the inclusion of knowledge about PMTCT drugs and its interaction 
with HIV status are shown in Model 3 (Table 4, Model 3, Column 3). Although the 
inclusion of the two variables reduced the difference in contraceptive use according to 
HIV status, knowledge about PMTCT drugs is not a significant predictor of contracep­
tive use. Furthermore, Model 3 is not an improvement over Model 1 (p = 0.576). The 
final model adds knowledge about ARV and knowledge about PMTCT drugs and 
their interactions with HIV status to Model 1 and shows similar results to Model 2, 
where only knowledge about ARV drugs was an important predictor of current use 
of contraception (Table 4, Model 4, Column 4). Again, this model is not superior 
to Model 1 (p = 0.386). Consequently, Model 1 was adopted as the best model for 
Nigeria and it is concluded that neither knowledge about ARV drugs nor knowledge 
about PMTCT drugs has an effect on the association between HIV status and contra­
ceptive use among women in Nigeria.
In Zambia, as in Nigeria, HIV status is significantly associated with current use of 
contraception among women, net of their background characteristics. While women 
who were HIV-positive were not different from their HIV-negative counterparts in 
this regard, women who did not know their HIV status were about 42% less likely to 
be using a method compared to their HIV-negative counterparts (Table 4, Model 1, 
Column 5). This model is superior to a model (not shown) that includes only women’s 
background characteristics as predictors of current use of contraception (p = 0.005). 
The results for Model 2 show that neither the main effect of knowledge about ARV 
drugs nor its interaction with HIV status was a significant predictor of current use 
(Table 4, Model 2, Column 6). Although the addition of these variables in Model 1 
attenuates the association between HIV status and contraceptive use observed in 
Model 1, Model 2 does not provide a better fit to the data than Model 1 (p = 0.387). 
Therefore, Model 1 is more parsimonious and its findings are preferred.
The inclusion of knowledge about PMTCT drugs and the interaction with HIV status 
produces a different conclusion. Both the main effect and the interaction effect were 
significant (Table 4, Model 3, Column 7). Women who did not know their HIV status 
and did not know about PMTCT drugs or believe that they work were about 68% less 
likely to be using a method compared with their counterparts who were HIV-negative. 
Similarly, HIV-negative Zambian women who knew of PMTCT drugs and believed 
that they work at least some of the time were 57% as likely to be using a contraceptive 
method as HIV-negative women who did not know about PMTCT drugs or believe that 
they are effective. Furthermore, women who did not know their HIV status but knew 
about a PMTCT drug that works at least some of the time were about two times as 
likely to be using a method as women who did not know their HIV status and were 
not aware of a PMTCT drug that works. Since Model 3 fits the data better than Model 
1 (p =  0.073), this finding is considered to be an improvement over the findings based
A R T and PM TCT knowledge, HIV status and fertility 595
on Model 1. Finally, when knowledge about ARV and PMTCT drugs and their inter­
actions with HIV status were added to Model 1, the findings remained similar to the 
findings under Model 3 (Table 4, Model 4, Column 8). The only exception is that this 
model shows that HIV-positive women were also less likely to be using contraception 
compared with HIV-negative women. However, since Model 4 does not produce a 
better fit to the data compared with Model 1 {p = 0.234) Model 4 was rejected and 
Model 3 retained as the most parsimonious for Zambia. It is therefore concluded that 
knowledge about PMTCT drugs has a significant impact on the association between 
HIV status and current use of contraception among women in Zambia.
The data used for this study have the strength of coming from a large-scale 
community-based survey with respondents selected through a probability process, and 
the data include self-reported information that are not available in standard Demo­
graphic and Health Surveys. However, there are some study limitations that may 
impact the results. First, the information on HIV status is from respondent self-reports 
of status. As with other sensitive and stigmatized issues, HIV status is mostly likely to 
be under-reported in a face-to-face interview. While the reports here also include 
reports obtained from a confidential sealed-envelope method used at the end of the 
face-to-face interview, under-reporting is still likely to be a problem. Second, the mea­
sures of knowledge about ARV and PMTCT drugs combined information from re­
spondents indicating that they know of drugs given by doctors or nurses for ART and 
PMTCT and that they believe the drugs are effective at least some of the time. It is 
therefore difficult to know how accurate these statements are. However, this is unlikely 
to constitute a serious bias for the study because its aim was to examine how percep­
tions about ARV and PMTCT availability and effectiveness shape childbearing desires 
and contraceptive use.
Discussion
This study provides new information about how knowledge about ARV and PMTCT 
drugs might moderate the impact of HIV status on women’s fertility preferences 
and contraceptive behaviour in Nigeria and Zambia. In Nigeria, knowledge about 
ARV drugs significantly altered the relationship between HIV status and desire for 
more children. HIV-positive women were more likely to want more children than 
HIV-negative women, when the effect of knowledge about ARV drugs was controlled. 
Additionally, HIV-positive women who knew about ARV drugs and believed that they 
are effective at least some of the time were less likely to desire more children compared 
with HIV-positive women who did not know about ARV drugs or believe that they are 
effective. This finding suggests that in the absence of knowledge about ARV drugs, the 
strong pronatalist nature of Nigerian society, which makes individuals want to prove 
their fertility and ensure continuity of their lineage, seems to weigh stronger in HIV­
positive women’s minds than the impact of HIV on women or the risk of transmission 
to the children they may bear. It is also likely that HIV-positive individuals who know 
about ARV drugs that work may have had more counselling on HIV and pregnancy, 
been exposed to more messages about the risks of MTCT, received more advice against 
continued childbearing by counsellors and may therefore be less likely to want another 
child. This would help explain why pronatalist norms do not continue to weigh
596 A. Banlcole et al.
strongly for women who know about ARVs, like they do for those who do not know 
about ARVs.
In Zambia it is knowledge of PMTCT drugs and belief in their effectiveness that 
influence the association between HIV status and desire for more children. HIV-positive 
women tend to be less likely to want more children than HIV-negative women when 
knowledge about PMTCT drugs is taken into account. However, HIV-positive women 
who knew of PMTCT drugs and believed they were effective at least some of the time 
were more likely to desire more children than HIV-positive women who did not know 
of a drug that works. This suggests that in the absence of knowledge about PMTCT 
drugs, the potential negative impact of HIV on the children women may bear seems to 
predominate in influencing HIV-positive women’s desire to have or not to have another 
child. Thus, when an HIV-positive woman is aware of a PMTCT regimen and believes 
in its effectiveness, she is likely to be more positive about having another child.
The different findings observed for Nigeria and Zambia with regard to the moderating 
impact of knowledge about ART and PMTCT on the relationship between HIV status 
and desire for more children may be due to a number of factors. First, the fertility tran­
sition and the desire for smaller family sizes are further along in Zambia than in Nigeria 
(National Population Commission & ICF Macro, 2009; Central Statistical Office et al., 
2009), so HIV-positive women in Zambia may not be under as much pressure to prove 
their fertility by having many children or another child as their Nigerian counterparts. 
Second, both ART and PMTCT are still relatively unknown and unavailable in Nigeria 
compared with Zambia (UNAIDS, 2013). Since the two HIV treatment and prevention 
services are taking off in Nigeria, the knowledge that ART can prolong the life of an 
HIV-positive person seems to weigh more than knowledge about the positive impact of 
PMTCT on reducing the risk of HIV in future children in the fertility decision-making 
of Nigerian women. In Zambia, perhaps because PMTCT is more novel than ART, 
knowledge about the former seems to be more of a determining factor in the decision 
of HIV-positive women to have or not have another child.
With regard to contraceptive use, in Nigeria the relationship between HIV status 
and current use of contraception is not affected by either knowledge about ARV drugs 
or knowledge about PMTCT drugs. HIV-positive women were not different from HIV­
negative women with respect to current use of contraception. Yet women who did not 
know their HIV status were significantly less likely to be using contraception than 
women who were HIV-negative, suggesting that women who did not know their 
HIV status might have been more ambivalent about having another child than HIV­
negative women. In Zambia, the relationship between PIIV status and current use of 
contraception was moderated by knowledge about PMTCT drugs. Women who did 
not know their HIV status were less likely to be using a method compared with HIV- 
negative women. However, among women who did not know their HIV status, those 
who knew about PMTCT drugs and believed that they are effective were more likely 
to be using a method than their counterparts who did not know of the existence of 
such a drug. Thus, in Zambia, knowledge about PMTCT drugs seemed to enhance 
the motivation of women who did not know their HIV status to use contraception. 
This finding is somewhat difficult to interpret. It may suggest that knowing that they 
are able to have a child without the risk of transmitting HIV to that child reduces the 
desire of women who do not know their HIV status to have more children out of fear
A R T and PM TCT knowledge, H IV status and fertility 597
that they may be HIV-positive in the future. Alternatively, the relationship may be 
spurious, given that knowledge about PMTCT and use of contraception are both likely 
to be associated with greater access to counselling on HIV and family planning.
Because knowledge about ARV drugs and PMTCT drags affects the childbearing 
desires and pregnancy prevention behaviours of Nigerian and Zambian women -  albeit 
not consistently across outcomes -  more efforts are needed to implement programmes 
to increase coverage and accurate knowledge about ART and PMTCT (as well as 
voluntary counselling and testing, VCT) in both countries. Although awareness of the 
two HIV treatments is high, especially in Zambia, evidence from other studies shows 
that detailed knowledge about HIV prevention in general is often much lower than 
awareness (Biddlecom et al., 2007). In order to improve detailed knowledge about 
ART and PMTCT, especially awareness that they are effective in preventing HIV 
transmission and reducing viral load, there is need to improve women’s access to better 
and accurate information about ART and PMTCT. As noted earlier, Zambia has 
recorded great success with ART and PMTCT coverage (UNAIDS, 2013). The country 
faces the challenge of continued expansion of these services to reach universal availability 
as well as ensure adequate service provision at the point of delivery. Nigeria has a much 
longer way to go with ART and PMTCT coverage. Although the government is making 
efforts to improve access to both of these treatments, it is important that these efforts be 
strengthened, especially given that in terms of the number of people living with HIV, 
Nigeria is only second to South Africa. To ensure adequate and effective coverage, 
programmes to promote knowledge about ART and PMTCT should concentrate on 
reaching women and their partners, not only at maternal and newborn care and HIV 
treatment facilities, but also at family planning centres and via general public education 
sources, particularly the mass media.
References
Akinyemi, J. O., Awolude, O. A., Adewole, I. F. & Kanki, P. J. (2010) Condom use among anti­
retroviral therapy patients in Ibadan, Nigeria. Journal o f Infection in Developing Countries 
4(8), 495-502.
Andia, I., Kaida, A., Maier, M., Guzman, D., Emenyonu, N., Pepper, L. et al. (2009) Highly 
active antiretroviral therapy and increased use of contraceptives among HIV-positive women 
during expanding access to antiretroviral therapy in Mbarara, Uganda. American Journal o f 
Public Health 99, 340-347.
Bankole, A., Biddlecom, A. & Dzekedzeke, K. (2011) Women’s and men’s fertility preferences 
and contraceptive behaviors by HIV status in 10 sub-Saharan African countries. AIDS Educa­
tion and Prevention 23(4), 313-328.
Biddlecom, A. E., Hessburg, L., Susheela, S., Bankole, A. & Darabi, L. (2007) Protecting the Next 
Generation in Sub-Saharan Africa: Learning from Adolescents to Prevent H IV and Unintended 
Pregnancy. Guttmacher Institute, New York.
Bonnenfant, Y. T., Hindin, M. J. & Gillespie, D. (2012) HIV diagnosis and fertility intentions 
among couple VCT clients in Ethiopia. AIDS Care 24(9), 1078-1086.
Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases Research Centre 
(TDRC), University of Zambia & Macro International Inc. (2009) Zambia Demographic and 
Health Survey 2007. CSO and Macro International Inc., Calverton, MD, USA.
598 A. Banlcole et al.
Cooper, D., Harries, J., Myer, L., Orner, P. & Bracken, H. (2007) “Life is still going on”: repro­
ductive intentions among HIV-positive women and men in South Africa. Social Science & 
Medicine 65, 274-283.
EIuI, B., Delvaux, T., Munyana, E., Lahuerta, M., Horowitz, D., Ndagije, F. et al. (2009) Preg­
nancy desires, and contraceptive knowledge and use among prevention of mother-to-child 
transmission clients in Rwanda. AIDS 23 (Supplement 1), SI 9-26.
Hayford, S. R., Agadjanian, V. & Luciana, L. (2012) Now or never: perceived HIV status and 
fertility intentions in rural Mozambique. Studies in Family Planning 43(3), 191-199.
Homsy, J., Bunnell, R., Moore, D., King, R., Malamba, S., Nakityo, R. et al. (2009) Repro­
ductive intentions and outcomes among women on antiretroviral therapy in rural Uganda: a 
prospective cohort study. PLoS ONE 4(1), e4149.
Johnson, K. B., Akwara, P., Rutstein, S. O. & Bernstein, S. (2009) Fertility preferences and the 
need for contraception among women living with HIV: the basis for a joint action agenda. 
AIDS 23 (Supplement 1), S7-17.
Kaida, A., Laher, F., Strathdee, S., Money, D., Janssen, P., Hogg, R. & Gray, G. (2010) Contra­
ceptive use and method preference among women in Soweto, South Africa: the influence of 
expanding access to HIV care and treatment services. PLoS ONE 5(11), e 13868.
Maharaj, P., Neema, S., Cleland, J., Busza, J. & Shah, I. (2012) Condom use within marriage: 
an assessment of changes in South Africa and Uganda. AIDS Care 24(4), 444-450.
Maier, M., Andia, I., Emenyonu, N., Guzman, D., Kaida, A., Pepper, L. et al. (2009) Antiretro­
viral therapy is associated with increased fertility desire, but not pregnancy or live birth, 
among HIV+ women in an early HIV treatment program in rural Uganda. AIDS Behaviour 
13, S28-37.
Makumbi, F. E., Nakigozi, G., Reynolds, S. J., Ndyanabo, A., Lutalo, T. et al. (2011) Associa­
tions between HIV antiretroviral therapy and the prevalence and incidence of pregnancy in 
Rakai, Uganda. AIDS Research and Treatment doi: 10.1155/2011/519492.
Mishra, V., Praween, A., Soumya, A., Yuan, G. & Wang, S. (2009) Changes in HIV-Related 
Knowledge and Behaviors in Sub-Saharan Africa. DHS Comparative Reports No. 24. ICF 
Macro, Calverton, MD, USA.
Myer, L., Carter, R. J., Katyal, M., Toro, P., El-Sadr, W. M. et al. (2010) Impact of antiretro­
viral therapy on incidence of pregnancy among HIV-infected women in sub-Saharan Africa: 
a cohort study. PLoS Med 7(2), e l000229.
Myer, L., Morroni, C. & Rebe, K. (2007) Prevalence and determinants of fertility intentions of 
HIV-infected women and men receiving antiretroviral therapy in South Africa. AIDS Patient 
Care STDs 21(4), 278-285.
National Population Commission (NPC) [Nigeria] & ICF Macro (2009) Nigeria Demographic and 
Health Survey 2008. National Population Commission and ICF Macro, Abuja, Nigeria.
Nattabi, B., Li, J., Thompson, S. C., Orach, C. G. & Earnest, J. (2009) A systematic review of 
factors influencing fertility desires and intentions among people living with HIV/AIDS: impli­
cations for policy and service delivery. AIDS Behavior 13(5), 949-968.
Rutenberg, N., Biddlecom, A. E. & Kaona F. A. D. (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.
Stata Corporation (2007) Stata Statistical Software: Release 8.0. Stata Corporation, College 
Station, Texas.
Taulo, F., Berry, M., Tsui, A., Makanani, B., Kafula, G., Li, Q. et al. (2009) Fertility intentions 
of HIV-1 infected and uninfected women in Malawi: a longitudinal study. AID S Behavior 13, 
S20-27.
Trinitapoli, J. & Yeatman, S. (2011) Uncertainty and fertility in a generalized AIDS epidemic. 
American Sociological Review 76(6), 935-954.
A R T  and PM TCT knowledge, HIV status and fertility 599
UNAIDS (2013) Global Report: UN AIDS Report on the Global AIDS Epidemic 2013. UNAIDS, 
Geneva.
United Nations (2002) HIVjAIDS and Fertility in Sub-Saharan A frica: A Review o f the Research 
Literature. Department of Economic and Social Affairs, Population Division, ESA/P/WP.174. 
United Nations, New York.
Yeatman, S. (2009) HIV infection and fertility preferences in rural Malawi. Studies in Family 
Planning 40(4), 261-276.