Reproductive Health Needs of Women Living with Hiv/aids in Yaounde, Cameroon

The population plagued with the HIV/AIDS pandemic in Cameroon is young, a generation that may desire or control fertility. For those who may become pregnant, the desire to have children may not be there. We carried out this study to look at the picture of the reproductive health needs of women living with HIV/AIDS in our setting. In this cross-sectional non-analytic design that lasted for three years, we employed both qualitative and quantitative methods to collect data from them after receiving ethical clearance (N221/CM/2009) from the National Ethics Committee. Consenting HIV infected women who were attending the " HIV Day Care " clinics and those who delivered and were in the post partum wards in four of our major hospitals in Yaounde were enrolled. Interviews were individualized. We used both CSPro version 4.1 and Statistical Package for Social Sciences (SPSS) version 19.0 softwares for data analysis. Four hundred and fifteen (415) women were enrolled; the mean age was 29 ± 7.8 years; the most represented age group was 24-29 years. They were single (36.14%), well educated (5 out of 10 had attained university level of education), 61.20% revealed that their partners knew their HIV status, 82.4% believed that screening for cancer of the cervix was necessary for their status and 47.70% would want to be screened for some or all STIs. About 36.86% had the desire to have children, 57.1% of those who delivered did not plan to have the pregnancies out of which 82% would have wanted a modern method of contraception but did not have (82% unmet needs). Modern contraceptive use was associated with age and individual characteristics such as level of education. It was 64.34% among women who had secondary level of education and below as against 35.66% among those who had high school level of education and above. Contraceptive use was also high among women who were unmarried as against those who were married (89.64% vs 10.36%). The desire to have children decreased as age increased (43.85% vs 18.79%) and was lower among married women compared to those who were single (13.01% versus 49.64%). These women were found to have high unmet needs for modern contraception and showed interest in STIs and cervical cancer screening.


Introduction
Since HIV/AIDS was reported in 1981 (CDC, 1981) and the virus isolated in 1983 [1], a lot of research has been carried out and efforts put towards its management and control.Financially, global spending on HIV/AIDS has increased 20 folds [2].
The apparent stabilization in prevalence rates in Cameroon (5.5% in 2004 and 4.3% in 2011 [3] [4]) could be argued out as a rise in AIDS related deaths and a decline in new infection.In 2009, UNAIDS estimated that there were over 33 million people infected with HIV worldwide and 70% were found in Sub-Saharan Africa.Also, 2.6 million individuals were newly infected with HIV within the same year [5].Cameroon with an HIV prevalence of 4.3% is considered one of the countries bearing the greatest burden in Central Africa.
To better manage the HIV/AIDS pandemic, a lot of input and efforts have been made to master and have a better understanding of its origin, structure, epidemiology, pathogenesis, diagnosis and management.Despite all these, a lot will be required in terms of resources to handle this pandemic (both human and material resources).We do not need to undermine programmatic challenges such as reinforcing prevention strategies that include prevention of mother to child transmission (PMTCT), provider initiated counseling and testing PICT) etc.We need to ensure that HIV infected individuals get the treatment and care they need and we need to develop strategies to improve the level of education and economic conditions of young women.Other challenges include the development, protection and promotion of the rights and duties of people living with HIV/AIDS and those of their spouses and children.
Young people are at the most risk.It is evident that they have reproductive health needs including family planning and fertility desires.Both the incidence and prevalence of women affected by HIV/AIDS are disproportionately high compared to men, representing more than half of the 33.3 million adults living with HIV/AIDS worldwide [5].Also, about 80% of HIV infected women are in their reproductive ages [5] [6].A range of successful and promising interventions to improve the sexual and reproductive health and rights of women living with HIV have been pronounced.These include the provision of contraceptives and family planning counseling as part of a common HIV package; ensuring early postpartum care, providing youth-friendly services, supporting information and skills building, supporting disclosure, providing cervical cancer screening, promoting condom use for dual protection against pregnancy and STIs/HIV and antiretrovirals [7].
Highly Active Antiretroviral Therapy (HAART) has improved the lives of women living with HIV/AIDS in Cameroon.Evidence shows that most of them need family planning, cervical cancer screening and screening for STIs [8] but these needs have not been evaluated here.In studies recently published, about 60% of pregnancies which occur among women living with HIV/AIDS in South Africa were unwanted, 50% in Uganda and 75% in Kenya [9].As most of these women are young and are on HAART in Cameroon, their desires to have sex must not be under looked and the efferent pregnancies may be unwanted.This may boost the unsafe abortion industry.According to the World Health Organization (WHO), each individual has the right to reproduce, to regulate fertility and to express sexuality without danger [9].
Most surveys carried out in many Sub-Saharan African countries show that a relatively good proportion of women living with HIV/AIDS know at least one modern method of contraception but the most widely used methods vary with countries.In Cameroon, the most widely used methods are the male condom and oral pills.In Kenya, it is the pill that is most commonly used [10].

Patients and Methods
It was a cross-sectional non-analytic study.We began from January 20 th 2010 and ended January 19 th 2013, a period of three years.Four main hospitals which are affiliated to the Faculty of Medicine and Biomedical Sciences of the University of Yaounde 1 formed our study sites.They were the university teaching hospital, the general hospital, the gynecologic and pediatric hospital and the central hospital.They all have patient affluence and have HIV day care units (accredited treatment centers) and maternities.We obtained ethical clearance from the National Ethics Committee and authorizations from the directors of these hospitals.We combined both qualitative and quantitative approaches that were concurrent.We chose Mondays, Wednesdays and Fridays for the qualitative approach and Tuesdays, Thursdays and Saturdays for the quantitative approach.HIV positive women who were attending the "HIV Day Care" clinics and those who delivered and were in the post partum wards in the four hospitals and who accepted freely to participate in the study were enrolled consecutively.In the qualitative approach, we began with consent formalities followed by description of the study objectives and procedures individually in a private room in the Day Care clinics.The next step was a detailed interrogation using a preconceived questionnaire.The same procedure was carried out for HIV infected women who were found in the post partum wards during the same period in the quantitative approach.We exported data from CSPro version 4.1 to the Statistical Package for Social Sciences (SPSS) version 19.0 software for analysis.We expressed results in means as a measure of central tendency for data with normal distribution while we used median where the distribution was skewed.Results are presented in tables and cross tabulations and comparism for statistical differences where appropriate is made.

Results
A greater proportion of the women (26.02%) were between 25 29 years, single (36.14%) educated (95.45%), unemployed (51.10%) and lived in urban areas (82.37%) (Table 1).Quite a good number of them had been living with HIV for more than one year (52.30%), with 61.11% of their partners knowing their HIV status.Only 7.73% of them had CD4 counts less than 350 and 82.37% were on HAART (Table 2).They showed interest in screening for STIs, screening for cancer of the cervix.They also showed interest in contraceptive use, desire to have children and in health education (Table 3).There was a significant relationship between age and contraceptive use (p = 0.045), level of education and contraceptive use (p = 0.015), marital status, religion and contraceptive use (p = 0.001), Table 4.The desire to have children was also significantly related to age (p = 0.001) and level of education (p = 0.004), Table 5.

Discussion
Reproductive health needs of women living with HIV/AIDS have been assessed and studies on this issue have  [10]- [13].This could be explained by the fact that sexual activity is high among respondents of these age groups [13].Also, these age groups have the highest prevalence of HIV among women in Cameroon [14].
The women studied were largely single (36.14%); married women represented 23.85% of the population, a finding consistent with reports in literature [15].They were educated as only 4% of them had not received any formal education, just as has been reported in earlier studies in Cameroon [16].Over half of the women had been diagnosed with HIV for more than a year (52.29%), same as reported in some studies in Cameroon, Nigeria and Uganda [16]- [19].With respect to CD4 count, 92.28% of the women enrolled had values greater than 350 and 82.40% were on HAART.A good number of them (47.70%)showed interest in screening for STIs, 82.40% in screening for cervical cancer and 38.79% in screening for breast cancer (Table 3).These services do not form the common package of continuum of care in the management of women living with HIV/AIDS in our country even though the United States Centers for Disease Control and Prevention (CDC) has included them as part of AIDS-related illnesses [20].A similar picture is observed in most of our countries as these services are not integrated or are just rudimentary [21] [22].
Demographic dividends of family planning are well known but unmet needs were evaluated to be very high in the general population of women living with HIV/AIDS in Cameroon including those who delivered (60.48% and 82.92% respectively).Up to 57.10% of women who delivered confessed they did not want these pregnancies.Similar findings have been reported in Sub-Saharan Africa [23]- [27].Contraceptive use was related to the level, of education, religion, employment and marital stati.Women who used modern methods of contraception were educated at or below secondary school level (64.34%), employed (89.88%), unmarried (89.64%),Christians (61.45%) (Table 4).Among the non-pregnant women interviewed, 36.86% of them had the desire to have children.The main reason for wanting to have children was lineage continuity.The desire to have children was inversely proportional to age and level of education.As age and level of education increased, the desire to have children decreased.Conversely, the desire to have children showed a direct relationship with unmarried and employed stati (Table 5).

Conclusion
Reproductive health needs vary among women living with HIV/AIDS in Cameroon.Unmet needs are high for family planning or cancer and STIs screening.Modern contraceptive use was linked to age, marital status and level of education.

Table 1 .
Socio-demographic variables of women living with HIV/AIDS in Yaounde.

Table 2 .
Past history and immunological status.

Table 4 .
Relationship between contraceptive use and socio-demographic characteristics.

Table 5 .
Relationship between fertility desire and socio-demographic characteristics.