Men and women in Sub Saharan Africa begin their reproductive lives facing the dual challenge of HIV infection and pregnancy planning. The Rakai district of Uganda represents a region where a generalized HIV epidemic has existed for the last two decades, where HIV prevalence is 11% and where the current unmet need for family planning is at 52%. Relatively stable HIV incidence coupled with treatment options means that today many people of reproductive age will live with HIV for many years. To date however, we know little about how HIV treatment and prevention shapes the fertility desires, behaviors, and outcomes of men, women, and couples - and how fertility influences HIV prevention. To address this gap, the proposed Prevention and Planning Linkages (Linkages) project first aims compare couples from four HIV concordant (both partners HIV+ or HIV-) and discordant groups (either sexual partner is HIV+) within the RCCS, examining men's and women's fertility desires, behaviors, and outcomes;agreement within couples;unmet need for contraception;and access to/utilization of HIV and RH services. Given the importance of both men and women in fertility decision-making, our investigations will focus on the role of both members of a couple in such decision-making. Using a mixed- method approach - used longitudinal cohort data and in-depth interviews with couples - we aim to provide a comprehensive perspective on the fertility desires, perceptions and behaviors of HIV concordant and discordant couples. Second, the Linkages project will explore trends in fertility desires, behaviors, and outcomes among HIV+ and HIV- women in relation to two phases of HIV prevention and treatment programs in Rakai: 1- post-availability of PMTCT and 2- post availability of ART. There is a dearth of research on fertility desires among a population-level cohort and how these desires have been affected by the changing dynamic of the HIV epidemic and treatment options. We will use historical data from sexually active women from the RCCS, to examine the trends in the fertility desires, behaviors and outcomes among HIV positive and HIV negative women over two phases of HIV treatment and prevention programs in rural Uganda. Finally, the Linkages project will identify trajectories i fertility desires and behaviors among women and men in the RCCS prior to and after seroconversion to infection, after seroconversion, and after gaining knowledge of personal or partner's infection. It is important to examine individual level variation in fertility desires and behaviors before and after HIV sero-conversion, as such a prospective analysis allows us to better understand the influence of HIV testing, HIV counseling and treatment on fertility related aspirations and behaviors, while conditioning on individual demographic and social characteristics. For this aim we will again use a mixed-method design - using longitudinal cohort data and matched 'case-control'qualitative interviews - to examine within-subject change among women and among men.
The proposed Planning and Prevention Linkages (Linkages) mixed-method study will explore the intersection of fertility desires, intentions, and behaviors among HIV positive and HIV negative men and women in rural Uganda. Using longitudinal quantitative data and qualitative data we will assess within couple differentials in fertility desie, perception and behaviors where partners are HIV discordant or concordant. We will also assess the changing trends in reproductive goals of women within the context of changing HIV programs and policies. And finally, we will use longitudinal quantitative and qualitative data to identify how fertility desires and behaviors change among men and women before they acquire HIV and after their HIV seroconversion.