The objective of this study is to help individuals and couples in African countries facing generalized HIV epidemics to achieve their family size goals and prevent unintended pregnancies while avoiding or coping with HIV infection. To do so, we propose to undertake new research that will improve provision of sexual and reproductive health services, including HIV- related care. Research on the influence of HIV status on childbearing intentions and contraceptive use in sub-Saharan Africa is very scarce. Existing studies have important limitations: most are small-scale and designed to assess the impact of interventions;most study HIV-positive people, sampled at health facilities, and most include women only, and lack the perspective of men, especially important in sub-Saharan Africa. To meet the study's objective, we propose three research efforts: (a) We will undertake new analyses of existing nationally representative survey data on men and women of reproductive age in 14 countries of sub-Saharan Africa, to provide a regional overview of the interrelationships between HIV status (based on biomarker testing, done in the surveys) and fertility desires and sexual and reproductive behaviors;bivariate and multivariate analyses will be done, as well as multilevel analyses for the 5 countries that also have information on availability of HIV-related services. (b) To provide deeper understanding of relationships between HIV status and attitudes regarding HIV-testing and services and the actions women and men are taking to achieve their fertility aspirations and prevent or cope with HIV infection, we will conduct a two-part study in one moderate-HIV-prevalence country (Nigeria) and one high prevalence country (Zambia): a quantitative survey of a community-based sample of 1300 men and women and a facility-based sample of 200 HIV positive people in each country;and in-depth interviews with 48 respondents systematically selected from the quantitative survey in each country. (c) We will conduct semi-structured interviews with about 80 health care providers in each country (Nigeria and Zambia) that provide sexual and reproductive health care, to improve understanding of the roles of providers in helping men and women meet their fertility aspirations and avoid or cope with HIV infection, with special attention to recent efforts to routinize and expand HIV testing. Project Narrative From the public health perspective, preventing the transmission of HIV and unintended pregnancy are very high priorities in sub-Saharan Africa, a region where HIV prevalence and unmet need for contraception are the highest in the world. Two recent trends} increased availability of HIV testing and of drug treatments for the HIV-positive} add to the urgency of the need for new research on the relationships between HIV prevention, HIV-related care, and prevention of unintended pregnancy. The proposed research will guide providers who face difficult choices and decisions in meeting these dual needs.
