An investigation of the impact of expanding access to Highly Active Antiretroviral Therapy (HAART) on sexual and reproductive decision-making and behaviours of women in high HIV prevalence settings in sub-Saharan Africa

Background: Given a paucity of information regarding the impact of expanding access to highly active antiretroviral therapy (HAART) on sexual and reproductive decision-making and behaviours of women in high HIV prevalence settings in sub-Saharan Africa, the objectives of thesis were: To assess whether use and duration of HAART was associated with (1) recent sexual activity among HIV-positive women across three high HIV prevalence settings; (2) fertility intentions and (3) contraceptive use and method mix patterns among women in Soweto, South Africa. And, (4) to develop a reliable HAART optimism scale for use among HIV-positive women and to test the scale’s validity against measures of sexual and reproductive decision-making and behaviours among women in Mbarara, Uganda. Methods: Quantitative data were drawn from surveys and medical record reviews conducted among 751 women attending the Perinatal HIV Research Unit in Soweto, South Africa (253 HAART-experienced, 249 HAART-naïve, and 249 HIV-negative) and 540 HIV-positive women (half of whom were receiving HAART) attending Mbarara University’s HIV clinic in Uganda. Surveys assessed socio-demographics, HIV status and HAART history, sexual and reproductive health decision-making and behaviours, HIV-related clinical assessments, and HAART optimism. Results: The analyses revealed that HIV-positive women receiving HAART are more likely to use contraception overall and dual protection in particular, with minimal differences in fertility intentions or sexual activity relative to their HAART-naïve counterparts. Moreover, optimism about the effects of HAART, rather than actual use or non-use, may be a more important predictor of fertility intentions and sexual activity of HIV-positive women. Overall, HIV-positive women are less likely to report fertility intentions and more likely to use contraception (and condoms in particular) relative to HIV-negative women from the same community. Conclusions: The findings highlight the potential great value and urgent need for improved integration between HIV prevention, testing, and HAART services and sexual and reproductive health (SRH) programming to address the diverse SRH needs of HIV-infected and –affected women in HIV endemic settings. Such integration is essential to better support the rights of all women to be sexually active and safely achieve their reproductive goals, while minimizing HIV transmission risks.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat