Improved health outcomes have resulted in people with HIV facing decisions about childbearing. We sought to understand factors associated with desire for a child among men and women in Malawi. HIV-infected men and women ages 18-40 were invited to participate in a brief interview about fertility desires. Single variable logistic regression was used to evaluate factors associated with the outcome of fertility desire. Additionally, multiple logistic regression was used to assess the relationship of all the factors together on the outcome of fertility desire. In-depth interviews with women were performed to understand experiences with reproductive healthcare. A total of 202 brief interviews were completed with 75 men (37.1%) and 127 women (62.9%), with 103 (51.0%) of respondents desiring a child. Being in a relationship (OR 3.48, 95% CI: 1.58 to 7.65, p = 0.002) and duration of HIV more than two years (OR 2.00, 95% CI: 1.08 to 3.67, p=0.03) were associated with increased odds of desire for a child. Age 36-40 years (OR 0.64, 95% CI: 0.46 to 0.90, p = 0.009) and having a living child (OR 0.24, 95% CI: 0.07 to 0.84, p=0.03) were associated with decreased odds of desire for a child. Seventy percent of women (n=19 of 27 respondents) completing semi-structured interviews who responded to the question about decision-making reported that their male partners made decisions about children, while the remainder reported the decision was collaborative (n=8, 30%). Eighty-six percent of women (n=36 of 42 respondents) reported no discussion or a discouraging discussion with a provider about having children. HIV-infected women and men in Malawi maintain a desire to have children. Interventions are needed to integrate safer conception into HIV care, to improve male participation in safer conception counseling, and to empower providers to help patients make decisions about reproduction free of discrimination and coercion.

Introduction: There are limited data on factors associated with retention in Option B+. We sought to explore the characteristics of women retained in Option B+ in Malawi, with a focus on the role of HIV disclosure, awareness of partner HIV status, and knowledge around the importance of Option B+ for maternal–child health.Methods: We performed a case-control study of HIV-infected women in Malawi initiated on antiretroviral therapy (ART) under Option B+. Cases were enrolled if they met criteria for default from Option B+ (out of ART for >60 days), and controls were enrolled in approximately 3:1 ratio if they were retained in care for at least 12 months. We surveyed socio-demographic characteristics, HIV disclosure and awareness of partner HIV status, self-report about receiving pre-ART education, and knowledge of Option B+. Univariate logistic regression was performed to determine factors associated with retention. Multivariate logistic regression model was used to evaluate the relationship between HIV disclosure, Option B+ knowledge, and retention after adjusting for age, schooling, and travel time to clinic.Results: We enrolled 50 cases and 153 controls. Median age was 30 years (interquartile range (IQR) 25–34), and the majority (82%) initiated ART during pregnancy at a median gestational age of 24 weeks (IQR 16–28). Ninety-one per cent of the cases (39/43) who started ART during pregnancy defaulted by three months postpartum. HIV disclosure to the primary sex partner was more common among women retained in care (100% versus 78%, p < 0.001). Odds of retention were significantly higher among women with: age >25 years (odds ratio (OR) 2.44), completion of primary school (OR 3.06), awareness of partner HIV status (OR 5.20), pre-ART education (OR 6.17), higher number of correct answers to Option B+ knowledge questions (OR 1.82), and support while taking ART (OR 3.65). Pre-ART education and knowledge were significantly correlated (r = 0.43, p < 0.001). In multivariate analysis, awareness of partner HIV status (OR 4.07, 95% confidence interval (CI) 1.51–10.94, p = 0.02) and Option B+ knowledge (OR 1.60, 95% CI 1.15–2.23, p = 0.004) remained associated with retention.Conclusions: Interventions that address partner disclosure and strengthen pre-ART education around the benefits of ART for maternal and child health should be evaluated to improve retention in Malawi’s Option B+ programme.

BackgroundThere is limited understanding of health care providers’ attitudes towards HIV-infected individuals’ reproductive choices, as well as knowledge about safer conception. Our study objective was to explore provider-level factors that serve as barriers and/or facilitators to the provision of reproductive and safer conception services for men and women living with HIV.MethodsTwenty-five providers were interviewed in four focus group discussions about their attitudes regarding childbearing by HIV-infected clients, reproductive health and HIV knowledge, and views and knowledge of safer conception.ResultsProviders reported ambivalence about supporting childbearing among their clients with HIV. They raised concerns about HIV-infected individuals having children, and in certain cases expressed judgment that people with HIV should not have children because of these concerns. Providers lack specific knowledge about safer conception strategies and have low level of knowledge of reproductive health, the efficacy of PMTCT, and the risks of pregnancy for HIV-infected women.ConclusionsProviders in our setting have complex attitudes about HIV-infected clients having children and lack knowledge to appropriately counsel clients about reproductive health and safer conception. Our findings highlight need for further research in this area as well as the need for provider training in reproductive health and safer conception.

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Global challenge-led research seeks to contribute to solution-generation for complex problems. Multicultural, multidisciplinary, and multisectoral teams must be capable of operating in highly demanding contexts. This brings with it a swathe of ethical conflicts that require quick and effective solutions that respect both international conventions and cultural diversity. The objective of this article is to describe the process of creating a toolkit designed to support global researchers in navigating these ethical challenges. The process of creating the toolkit embodied the model of ethical research practice that it advocates. Specifically, at the heart of ethical decision-making is consideration of the following: Place, solutions must be relevant to the context in which they are to be used; People, those impacted by the outcomes must be partners in co-creation; Principles, ethical projects must be guided by clear values; and Precedent, the existing evidence-base should guide the project and, in turn, the project should extend the evidence-base. It is the thesis underlying the toolkit that consideration of these 4Ps provides a strong basis for understanding ethical conflicts and allows for the generation of potential solutions. This toolkit has been designed in two phases of collaborative work. More than 200 researchers participated from more than 30 countries and more than 60 different disciplines. This allowed us to develop a model for contextual, dynamic analysis of ethical conflicts in global research that is complementary to traditional codes of ethics. It emphasizes the need to consider ethical analysis as an iterative, reflective, process relevant at all stages of the research journey, including, ultimately, in evaluating the legacy of a project. The toolkit is presented as an open access website to promote universal access. A downloadable “pocket guide” version is also now available in 11 languages.