Perceived effect of HIV status and ART treatment on fecundity in sub-Saharan Africa: Findings from a systematic scoping review

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El Ayadi, Njeri Wairimu, Jordan Ackernecht, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7103751/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Advances in antiretroviral therapy (ART) enable women living with HIV to safely conceive and give birth without vertical transmission. However, in sub-Saharan Africa, 1 in 5 couples experience infertility and women living with HIV face even higher rates. Several longitudinal studies show that ART and virologic suppression improve fertility/fecundity, yet this benefit is often overlooked in ART adherence education. Objectives: The objective of this scoping review is to map the literature on people’s understandings and beliefs of; 1) the relationship between HIV and fecundity, and 2) the effectiveness of ART in reducing HIV's adverse impact on fecundity. We also documented suggestions for interventions to raise awareness around how HIV and ART affect fecundity. Study Design: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct a scoping systematic search of English and French literature in sub-Saharan Africa from 2000–2024 with keywords related to HIV, ART, and fecundity/fertility. Three independent reviewers screened texts, read a subset of full texts, and used a charting table to summarize results and identify emerging themes. Principal Findings: Of 1,981 sources identified, only 12 met our inclusion criteria. Most did not explicitly examine perceptions of HIV, ART, and fecundity but related topics. Despite the scarcity of research, we uncovered the following themes: (1) Beliefs that HIV and PrEP cause infertility exist but have not been widely documented; (2) Perceptions that ART improves health before pregnancy motivates women to adhere and provides hope about future pregnancy; (3) Stigma from providers discourages women living with HIV from seeking preconception care; and (4) Lack of awareness among providers and patients about the impact of HIV on pregnancy, highlights the need for provider training. Conclusions & Implications for Policy and Practice: Research on perceptions of HIV, ART, and fecundity in sub-Saharan Africa is sparse despite evidence that HIV reduces fecundity while ART increases the likelihood of pregnancy. Given the cultural importance of motherhood and the stigma associated with infertility in sub-Saharan Africa, addressing this gap could improve ART adherence and help couples living with HIV build their families. HIV fertility fecundity sub-Saharan Africa scoping systematic review Figures Figure 1 Background A 2022 World Health Organization (WHO) meta-analysis reported that in sub-Saharan Africa (SSA), 1 in 5 couples experience infertility—the inability to conceive after 12 months of unprotected sex [1]. Women living with HIV face even higher infertility and subfertility (an extended period of unwanted non-conception without confirmed infertility) rates than their HIV-negative counterparts [2–5]. A study using Demographic Health Survey data including objective biomarkers of HIV status from eleven African countries found that women living with HIV had a 25% average reduction in fecundity [3]. Moreover, among a subset of women who unsuccessfully tried to become pregnant for three months, women living with HIV had half the odds of subsequently becoming pregnant compared to women without HIV [3]. A 2021 study from South Africa corroborated this finding, reporting that women with high viral loads (a marker for antiretroviral therapy [ART] non-adherence) are more than twice as likely to miscarry than women who are virally suppressed [6]. Several factors contribute to elevated infertility and subfertility risk among women living with HIV, largely related to immune and endocrine system dysfunction. For example, women living with HIV often have increased rates of prolonged anovulation and amenorrhea, and increased risk and severity of other co-infections, such as chlamydia and gonorrhea, which can lead to pelvic inflammatory disease (PID), a leading cause of tubal factor infertility [7–11]. HIV also affects male fertility, but the sperm abnormalities found in HIV patients are poorly understood, since both the virus and treatment (ART) can cause changes [12,13]. Despite the varied effects, men on ART show improvement in sperm quality after six months on ART [14]. Infertility and HIV combined can create a high burden of distress for women in general, but especially in SSA, where motherhood often defines a woman’s worth [15–17]. A 2024 scoping review on the social impacts of infertility and HIV found that both an HIV diagnosis and infertility were stigmatizing experiences for women who wanted children, but the stigma of infertility had a greater negative impact on women than an HIV diagnosis [18]. A 2025 qualitative study among sero-different couples in Uganda found that having more children helped avoid infertility stigma and was prioritized over HIV prevention [19]. Research among women living with HIV in SSA highlights the normative perception that having children makes you a “full person” [20] and infertility in this setting is responsible for significant social, psychosocial and economic costs [21]. Our prior work in Kenya illuminated the family and societal pressure to have children soon after marriage to prove one's fertility and as part of the spoken or unspoken contract of marriage [17]. Fortunately, advances in ART allow women with HIV, including women in sero-different relationships, to safely conceive and prevent vertical transmission [22, 23]. In 2015, the WHO began recommending universal ART at HIV diagnosis, regardless of CD4 count or other indicators to improve health status and prevent transmission [24]. Before this, pregnant women were automatically ART eligible but otherwise healthy women were not ART-eligible pre-conception. ART suppresses the virus, making it undetectable—and untransmittable (“undetectable = untransmittable”) [22]. Since this shift, studies show that women on ART have higher fertility rates [25]. A 2016 review found that ART improves women’s fecundity after about a year of consistent use [26]. As ART access expands, the fertility gap between HIV-positive and HIV-negative women continues to close [25, 27, 28]. But ART adherence challenges persist; only 78% of people living with HIV in Eastern and Southern Africa are virally suppressed [29]. Factors influencing adherence are complex, intersectional, and likely gender-specific across settings. Some notable barriers include HIV stigma and confidentiality concerns, lack of family and community support, physical, economic, and emotional stress, depression, alcohol or drug use [30, 31]. Given the multi-level barriers, a multi-faceted approach is needed to address adherence but thus far, awareness around HIV, ART, and fertility has not been utilized as a potential ART driver. To promote ART adherence and help women and couples reach their family building goals, we need a better understanding of how people perceive the link between HIV, ART, and fecundity. To our knowledge, there has been no systematic or scoping review of people’s perceptions of the relationship between HIV, ART, and fertility/fecundity performed to date. This systematic scoping review fills that gap, collating targeted valuable information from across the literature to inform ART adherence efforts and, ultimately, to help couples living with HIV reach their family building goals. Without attention to this area of research, we may be missing salient and potentially effective messages to improve ART adherence. Methods Our scoping review methodology is informed by the Arksey and O’Malley [32] and Levac et al frameworks which outline the required steps to complete a rigorous review [33] and is in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) guidelines [34]. We opted to conduct a systematic scoping review rather than a systematic review due to the wide-ranging nature of our questions and the fact that our findings are intended to identify research gaps and synthesize the literature rather than guide medical or policy decisions [35]. Given the absence of previous reviews, a scoping review is an appropriate first step to explore the existing literature on perceptions of HIV, ART, and fertility [35]. Objectives The objective of this scoping review is to map the literature on people’s understandings and beliefs of; 1) the relationship between HIV and fecundity, and 2) the effectiveness of ART in reducing HIV's adverse impact on fecundity. Additionally, we aimed to uncover gaps in the literature and to document suggestions for areas of intervention to increase awareness around how HIV and ART affect fecundity. To achieve these objectives, our review targets the following primary and secondary research questions: Primary Research Questions: What are people’s understandings of the relationship between HIV and fecundity in sub-Saharan Africa? What are people’s understandings of the relationship between ART and fecundity in sub-Saharan Africa? Secondary Research Questions: What are the authors’ recommendations for interventions to raise awareness around how HIV and ART affect a couple’s ability to conceive? What are the research gaps for future research? Key Concepts In this scoping review, we are referring to fecundity as a woman’s ability to biologically conceive [3]. Fertility refers to the number of children that women have and fertility preferences are the number of children that women want to have. Sub-fertility refers to an extended period of unwanted non-conception without confirmed infertility (often defined as not having conceived within six months of attempted conception) [4]. Given that they are often used interchangeably, and we are interested in beliefs, norms and perceptions, we used all terms in our search but during screening and full text review, we only included papers that refer to perceptions about HIV or ART and fecundity. Data Sources and Management We reviewed PubMed and all data and articles were managed within Zotero reference manager (Fairfax, Virginia, USA) and Covidence systematic review (Melbourne, Victoria, Australia) softwares. After our initial search and discussions with HIV and infertility experts, we decided not to search databases outside of PubMed or conduct a grey literature review given the dearth of research at this intersection. Search strategy We worked collaboratively with a medical librarian at (masked for blind review) with training and experience in systematic and scoping reviews to design our search strategy using an iterative process that follows an established search method. We employed a three-step search strategy for identifying published studies. First, we conducted a preliminary search in PubMed to identify key articles on our topic and begin the process of term harvesting, described below. From these key articles, we extracted text words and MeSH terms from titles, abstracts and author-supplied keywords and built a comprehensive list of keywords and controlled vocabulary terms, to inform our search strategy development. The search strategy was developed in PubMed, using controlled vocabulary (eg, MeSH, Emtree, thesaurus terms) where databases allow. The medical librarian reviewed multiple iterations, including the final search strategy, and discussed with authors which terms to add or remove to optimize the search for our research questions, using the Peer Review of Electronic Search Strategies guidelines [37]. Third, the reference lists of all included reports and articles were searched to identify any additional eligible studies (n=9 additional studies were included). The search strategy combined three main concepts: 1. HIV/ART; 2. fecundity/fertility/infertility/subfertility; and 3. knowledge/attitudes/beliefs/perceptions. Boolean logic was applied by combining similar key words and controlled vocabulary. Table 1 shows our strategy which produced 1,984 results: Table 1 Search Strategy (HIV [tiab] OR "HIV"[Mesh] OR “Human immunodeficiency virus” [tiab] OR “HIV infections” [tiab]) AND (attitudes [tiab] OR attitude [tiab] OR belief [tiab] OR beliefs [tiab] OR knowledge [tiab] OR perception [tiab] OR perceptions [tiab] OR perspectives [tiab] OR understand [tiab] OR understanding [tiab] OR idea [tiab] OR ideas [tiab]) AND (fecundity [tiab] OR fecund [tiab] OR conceive [tiab] OR childbearing [tiab] OR fertility [tiab] OR fertile [tiab] OR subfertile [tiab] OR subfertility [tiab] OR reproductive [tiab] OR pregnancy [tiab] OR pregnant [tiab]) AND (“sub-Saharan Africa ” [tiab] OR Africa [tiab] OR Angola [tiab] OR Benin [tiab] OR Botswana [tiab] OR “Burkina Faso” [tiab] OR Burundi [tiab] OR “Cabo Verde” [tiab] OR Cameroon [tiab] OR “Central African Republic” [tiab] OR Chad [tiab] OR Comoros [tiab] OR Congo [tiab] OR “Côte d'Ivoire” [tiab] OR [tiab] OR Djibouti [tiab] OR Equatorial Guinea [tiab] OR Eritrea [tiab] OR Eswatini [tiab] OR Ethiopia [tiab] OR Gabon [tiab] OR Gambia [tiab] OR Ghana [tiab] OR Guinea [tiab] OR “Guinea-Bisub-Saharan Africa u” [tiab] OR Kenya [tiab] OR Lesotho [tiab] OR Liberia [tiab] OR Madagascar [tiab] OR Malawi [tiab] OR Mali [tiab] OR Mauritania [tiab] OR Mauritius [tiab] OR Mayotte [tiab] OR Mozambique [tiab] OR Namibia [tiab] OR Niger [tiab] OR Nigeria [tiab] OR Rwanda [tiab] OR “Sao Tome and Principe” [tiab] OR Senegal [tiab] OR Seychelles [tiab] OR “Sierra Leone” [tiab] OR Somalia [tiab] OR “South Africa” [tiab] OR “South Sudan” [tiab] OR Sudan [tiab] OR Togo [tiab] OR Tanzania [tiab] OR Uganda [tiab] OR Zambia [tiab] OR Zimbabwe [tiab]) NOT (“sero-discordant” NOT discordant [tiab]) We conducted the search on November 1 2024, and included articles from 2000 through 2024. We chose to include papers from the year 2000 because beliefs and information spread from person to person so someone living with HIV now may be influenced by what others in their community (e.g., their grandparents, in-laws, friends, etc.) believed about how HIV and ART affect fertility from years ago [38]. Additionally, while the WHO’s recommendation for universal ART began in 2015, implementation of these guidelines varied across countries [39]. Therefore, we included studies published up to 15 years prior to the shift in WHO ART recommendations. Inclusion and exclusion criteria Inclusion and exclusion criteria for selection of eligible studies was developed using the population, concept, context elements proposed for scoping reviews by the Joanna Briggs Institute (Table 2) [40]. No limits were placed on study design; we included both quantitative and qualitative methods. We included studies that took place in, or report on findings from SSA, written in English or French. Table 2 Population, concept and context for identification of eligible studies Criteria Description Population Any perceptions including of people living with HIV, the providers who care for them, or anyone else (e.g., their social networks including community members, friends, family, and anyone in the general population). Concept Both quantitative and qualitative research around HIV, ART, and fertility. Context Sub-Saharan Africa; articles written in English or French. Study selection Three reviewers (masked for blind review) participated in the screening and full text review. Two of the reviewers are from U.S. institutions and one reviewer is from a Kenya based institution. Their backgrounds range from public health to anthropology to health services research. Reviewers independently screened titles and abstracts of all articles (two reviewers per article), followed by full-text screening and data extraction. Reviewers met weekly during the abstract review process to discuss challenges and ambiguities related to study selection. Study screening progress is documented in a modified PRISMA flow chart (Figure 1). Extraction of results After the search was completed, all citations were imported to Covidence for management and screening. Duplicates were removed and additional records were identified through hand searching including reviewing the references for included papers. Next, a sequential screening process was implemented. First, we reviewed titles and abstracts for inclusion to identify all potentially relevant reports, then we reviewed full texts for definitive classification of inclusion or exclusion. We used a charting table to record information from each publication. Charting is a method for synthesizing and interpreting qualitative data by sifting, sorting, and analyzing material according to key issues and themes. Table 3 below, “Characteristics and findings of included studies related to perceptions about HIV or ART and fecundity” is the final charting table that reports on results related to our research questions only. We excluded articles that ultimately did not align with our inclusion criteria after full text review leaving 12 articles in the review. Due to the scoping nature of our research questions, we did not appraise the quality of the papers. Data synthesis We present the findings from our scoping review in both a table format with year of the literature, countries of origin, research methods, etc. following the general format of our charting table (Table 3) and in a narrative format. Reviewers thematically analyzed the data according to our two primary and two secondary research questions. Additional content experts (a medical doctor who cares for people living with HIV and a social scientist who conducts HIV and ART adherence research in Kenya) also contributed to interpretation during this step. We created an excel document with all papers where we conducted the full text review (n=32) and described in detail the methods and findings according to each of the four research questions. We highlighted the findings that were relevant to our research questions so that we could easily determine which to include in the final review and which to discuss during meetings. Three reviewers (co-authors ES, NW, and JA) read through the papers to ensure that we could break a tie if two researchers disagreed whether to include a study or not. We met weekly during this process to discuss findings within the charting table and ultimately agreed on the twelve papers listed below. Results Figure 1 shows the PRISMA flow diagram for study selection process. We initially identified 1981 papers. In the first stage, three duplicates were removed. A total of 1955 were ineligible and nine were added, which we found through other sources, including a hand search of references. In the second stage, we conducted a full text review of 32 papers. Of the 32 studies, 20 did not meet the inclusion criteria as they were not reporting on our primary or secondary research questions but on tertiary topics such as prevention of vertical transmission, safe conception for sero-different partners, and fertility desires (see Supplemental File 1 Excluded Studies). While a total of 12 studies met our study inclusion criteria, the level of relevance to our research questions varied. All included papers referenced our phenomena but did not report in depth findings. In other words, we did not find a paper with the aim of reporting on perceptions about the relationship between HIV, ART, and fecundity illuminating a scarcity of literature on this topic. Table 3 shows information about the selected publications. These papers use data from across sub-Saharan Africa including Uganda, Senegal, Malawi, South Africa, Zimbabwe, Kenya, Tanzania, Botswana, Ghana, and Zambia. Eleven papers were published in English, and one was published in French in a range of journals including public health, reproductive health, and HIV focused journals. The papers were published between 2009 and 2019 but nine out of twelve before 2015 when ART was recommended for all people when diagnosed with HIV regardless of CD4 count. We included eleven qualitative studies and one quantitative study. Table 3. Characteristics and findings of included studies related to perceptions about HIV or ART and fecundity Author(s) Year Country Data collection methods & participants Findings and Recommendations King et al. (2011) 41 Uganda In-depth interviews Women on ART (n=29), Partners of women on ART (n=16) Couples commonly held the belief that HIV made them infertile. As a result, some did not use family planning (or used inconsistently) so in several cases, pregnancy was a surprise. Both men and women associated ART with positive outcomes such as better physical and emotional health which led to increased sexual desire and ultimately pregnancy for some. Recommendation: Integrate reproductive health education and family planning services into ART programs for both men and women that focus on restoring fertility following ART initiation. *Sow (2014) 42 Senegal Repeated semi-structured individual interviews, group interviews, participant observations. Healthcare professionals (n=21) HIV-negative pregnant women (n=20) HIV-positive women (n=25) There were concerns about taking ART during pregnancy. Couples sometimes seek guidance from healthcare providers or from women living with HIV who have become mothers. Although all the women surveyed express fear of the negative consequences associated with having multiple pregnancies due to their HIV status, the majority do not use contraception continuously. Social workers seem to be more attentive to the women’s desire to have children than medical doctors. Provider counseling is often limited to the maternal "duty" or "responsibility" to prevent vertical transmission. Recommendations: In a context where the pressure to bear children is strong, the biomedical system should be re-structured to better support women’s reproductive needs and include men in educational efforts. Chitukuta et al. (2019) 43 Malawi Uganda South Africa Zimbabwe In-depth interviews and focus group discussions HIV-negative, sexually active women (n=214) Participants believed that the drugs inside the vaginal ring for HIV-1 prevention, were intentionally there to cause infertility so as “to limit the Black population” resulting in fear of using it. Ujiji et al. (2010) 44 Kenya In-depth interviews Pregnant women (n=9) Women who had delivered in the past 12 weeks (n=6) Women who were seeking to become pregnant (n=5) Some women perceived counselling to improve their CD4 cell count before trying to conceive as restrictive; they felt it could delay pregnancy and were considered tests to determine their capability of getting pregnant. Recommendations: Counseling should focus on bridging the gap in knowledge between lab test results and health behaviors (like ART adherence), which could help women understand how this may affect their goals for having children. Nduna & Farlane (2009) 45 South Africa Semi-structured interviews, focus groups and a series of participatory workshops Black African women (n=78) Women considered their partners desires for children, especially when the partner did not have HIV or other children, which caused them some anxiety. On the one hand, they wanted to meet these desires but were wary of potential health risks. Some participants felt that getting pregnant would be too strenuous on their bodies given their HIV diagnosis. Some expressed a fear of dying because their bodies would be “drained of nutrients” while pregnant and living with HIV. Women felt that ART made them fit for pregnancy as it boosted their immunity but were still worried about whether ART would help them to live long enough to raise their children. They reported that ART helped them fulfill childbearing expectations from partners and families. Communicating fertility desires with healthcare providers was encouraged to receive necessary counselling but women often did not seek preconception counseling/care due to stigma from providers against women living with HIV having children. Recommendations: Authors noted that women living with HIV need to be informed about how HIV affects pregnancy outcomes and vice versa. Despite healthcare providers willingness to have fertility discussions, they often discourage women living with HIV from getting pregnant. Saleem et al. (2016) 46 Tanzania In-depth interviews Healthcare providers (n=30), Men with HIV (n=30) Women with HIV (n=30) Healthcare providers felt limited in their capacity to support patients living with HIV about their reproductive health because they lacked training. They reported that they did not know specific policies or updates in national guidelines, so providers often referred these clients to other more qualified providers. Some providers and patients reported that it was important for men and women living with HIV trying to conceive to first get their health checked though providers had different opinions about the recommended CD4 cell count before conception. A few providers discouraged their patients from having children due the effects of pregnancy on their health especially if they already had other children. Similarly, patients were worried that providers would discourage them from having children with some reporting that providers told them they could not have children due to their HIV status. Recommendations: Integration of HIV and sexual and reproductive health services to support people living with HIV and their partners in planning pregnancies and health management. Sofolahan & Airhihenbuwa (2013) 47 South Africa Focus group discussions (n=4) Women living with HIV on ART (n=35) Pregnancy promoted adherence to ART as one participant said, “I normally don’t take pills, but I take them for my baby.” Some women reported that healthcare providers discourage women living with HIV from getting pregnant without proper counseling. Recommendations: Capacity-building programs for healthcare workers could ensure that providers are taking into consideration the sexual and reproductive desires of women living with HIV during counselling. Gutin et. al (2020) 48 Botswana In-depth interviews Sexual and reproductive health/HIV providers (n=10) Women living with HIV (n=10) Healthcare providers had reservations about childbearing including repeat pregnancies, among people living with HIV as they feared vertical transmission, which made women living with HIV feel unsupported and discouraged. Nevertheless, some providers felt that they should offer their clients counselling without preventing them from having children. Others however withheld information about safer conception. Recommendations: There is a need to educate healthcare providers about the Undetectable=Untransmittable (U = U) campaign to uphold reproductive rights for women living with HIV and reduce transmission of HIV. Additionally, providers need comprehensive safer conception training to support couples and reduce health risks associated with HIV transmission. Yeatman (2011) 49 Malawi In-depth interviews with men and women living with HIV (n=58) Most participants believed that pregnancy would negatively impact their health due to living with HIV. In other words, pregnancy would “weaken their blood” and “make them ill” causing their HIV to progress. The belief that pregnancy is dangerous if you are living with HIV goes hand in hand with its corollary: if you avoid pregnancy, you will live longer. Laar (2013) 50 Ghana Surveys n=35 heath care workers: n=32 nurses, n=3 medical officers providing testing and counseling services to HIV patients Providers demonstrated a high level of ignorance regarding the various reproductive options available to women living with HIV. Only ~10% of the providers were aware of some reproductive options for women living with HIV. A quarter would advise them to have unprotected intercourse as an option to conceive. Some of the providers openly expressed their inability to give qualified and relevant advice to women living with HIV. These findings suggest that patients living with HIV do not receive comprehensive information about their reproductive options. Kastner et al. (2014) 51 Uganda In-depth interviews n= 25 pregnant women receiving ART Women reported that counseling on childbearing was largely discouraging, emphasizing the risks of childbirth to their health given their HIV status. Despite perceived dangers of pregnancy while living with HIV, many women noted that social pressures to have children outweighed risks. While formal pregnancy counseling was limited, peer support at clinics provided encouragement, fostering an informal network where women shared experiences. Provider guidance on ART’s role in reducing health risks made women feel hopeful about pregnancy. ART access also increased optimism about childbearing, helping women regain a sense of normalcy, reduce stigma, and balance reproductive roles with their health and family well-being. Recommendations : Addressing gaps in clinical counseling is crucial for integrating sexual and reproductive health programs. Supporting healthcare workers to routinely assess fertility goals can improve reproductive care by providing effective contraception for those avoiding pregnancy and safer conception counseling for those who wish to conceive. Integrating HIV and reproductive health services is essential to supporting desired pregnancies and prevent unintended ones. Public health messaging should target women living with HIV, healthcare providers, and communities to raise awareness about pregnancy experiences on ART and ensure informed reproductive choices. Harries et al., 2007 52 South Africa In-depth interviews Health care providers (n=14) Public sector policy makers in the HIV field (n=12) Healthcare providers believed that women should have a sufficiently high CD4 count and access to ART before getting pregnant. While others emphasized the importance of reproductive rights and person-centered care. Some doctors were concerned that if healthcare providers overlooked patients' plans to become pregnant and did not offer proper counseling, those patients might stop their ART treatment. Most policy makers felt that developing counseling guidelines for women who want to get pregnant while living with HIV would be valued. Without guidelines providers would continue "bumbling along" and make “ad hoc” recommendations. * Published in French Our systematic scoping review uncovered four emerging themes about people’s understandings of the relationship between HIV, ART, and fecundity in SSA including: (1) Beliefs that HIV and PrEP cause infertility exist but have not been well documented (two studies); (2) Perceptions that ART improves health before pregnancy motivates women to adhere and provides hope about future pregnancy (five studies); (3) Stigma from providers discourages women living with HIV from seeking preconception care (six studies); and (4) Lack of awareness among both providers and patients about the impact of HIV and ART on pregnancy (eight studies). Beliefs that HIV and PrEP cause infertility exist but have not been widely documented We found a limited number of studies reporting that HIV or HIV prevention technologies (e.g., PrEP) cause infertility. Specifically, we found only two studies directly related to beliefs around HIV and fecundity [41, 43]. One study reported that couples believed that having HIV would make them infertile, so they were not using contraception [41]. Couples reported that since they were having sex without a condom and not getting pregnant, this was further evidence to corroborate this belief. When some couples subsequently did get pregnant accidentally, they were surprised [41]. We found one study about HIV prevention (the vaginal ring) and beliefs about infertility. This study uncovered the widespread belief among participants that the vaginal ring for HIV prevention causes infertility. Specifically, they believed that the drugs inside the ring had been put there deliberately to cause infertility and “to limit the Black population” [43]. Two other studies were related to this topic but did not directly report beliefs around HIV and fecundity. In one study, participants living with HIV reported not using contraception but stated that “they knew they could get pregnant” [42]. Another study reported that women believed that getting pregnant would hasten the progression of their HIV diagnosis making pregnancy too dangerous in general for their health [49], but this study focused more on how pregnancy would negatively affect their HIV prognosis, not their fecundity. Perceptions that ART improves health before pregnancy motivates women to adhere and provides hope about future pregnancy Overall, beliefs about ART were positive with women and providers noting the benefits for protecting women’s health, fecundity, and once pregnant, the baby’s health. All studies that reported on ART and fecundity noted positive perceptions around ART and pregnancy including improved physical and emotional health due to ART adherence which increased desire for sex resulting in an increase in pregnancy in some cases [41]. Studies also reported restored hope and a feeling of optimism about pregnancy [47, 51] and the sentiment that it would improve their immunity and therefore their chances of pregnancy [45, 42]. In one study, participants directly stated that ART enabled them to meet the expectations of their partners and families to bear children stating, “this pill [a reference to ART] is important to give in-laws children” [45]. The same paper reported that healthcare workers either encouraged women to take ART to improve pregnancy chances while others stigmatized or discouraged women living with HIV from getting pregnant at all. It was not always clear if the optimism about pregnancy was linked to participant perspectives that ART increased their biological ability to conceive (their fecundity) or whether it reflected perspectives about ART preventing vertical transmission or increasing their lifespan to be able to live long enough to care for their children. Despite these positive perceptions about ART and fecundity, some participants were still concerned about whether ART would allow them to live long enough to raise their children, and providers sometimes exacerbated these fears by only recommending one child [45]. In some studies, women reported that their provider advised them to “get healthy” or improve their CD4 count via ART before attempting pregnancy [44, 46]. In one study, women reported that this felt overly intrusive as this could delay their pregnancy. They felt that the clinic was restricting them and expecting them to ask for permission to become pregnant. They felt the tests done by the clinic to decide on their capability to become pregnant unnecessary [44]. And in a study which documented medical providers perceptions, some stated that women should have a sufficiently high CD4 count and access to ART before getting pregnant, while others emphasized the importance of reproductive rights to decide on their own when they want to get pregnant [52]. Stigma and lack of clear guidance from providers discourages women living with HIV from seeking preconception care Although women living with HIV can safely conceive and give birth if they adhere to ART, we found that many women felt stigma from their provider, especially if they wanted a second or third child, and this discouraged them from seeking care. Some health care workers reported being open to discussions of fertility plans but data from patients suggests that providers can dissuade women living with HIV who would like to get pregnant [45, 48). Therefore, authors report that women often do not seek preconception counseling/care due to anticipated stigma from providers that having multiple children while living with HIV is risky [45]. Some providers voiced uneasiness about repeat pregnancies, suggesting that one pregnancy was acceptable but repeat pregnancies were concerning because of health risks for the mother and transmission risks for the partner and infant. When trying to communicate these concerns, providers sometimes used language that suggested to women living with HIV that they were discouraging pregnancy [45, 46, 48]. One study reported that social workers seem to be more person-centered around women’s desire to have children than medical providers [42] presenting a potential task-shifting or training opportunity. Lack of awareness among both providers and patients about the impact of HIV on pregnancy, highlights the need for provider training Most of the papers in this review (8 out of 14) mentioned a lack of understanding about how HIV and ART affect fecundity. This was true for both providers and patients. Several papers mentioned a notable gap in provider training around HIV and sexual and reproductive health and a call to increase community health worker training specifically [46, 47]. Some healthcare providers felt limited in their capacity to offer their clients living with HIV counseling on safe conception and pregnancy as they were not adequately trained [46]. Authors mentioned this is critical because as previously mentioned, patients reported that some providers advise them not to have children or not to have more than one child [45, 48, 46]. One study reported, “women living with HIV require information on the impact of HIV on pregnancy outcomes and vice versa” [45]. This was common across studies; several studies reported that women believed that pregnancy would weaken their immune system thereby worsening their overall health and not getting pregnant was best for their health [45, 49]. Current HIV services for women of reproductive age do not appear to proactively address issues of pregnancy and HIV progression, need to change ART regimens when considering or while pregnant, and post-partum recovery [45]. Studies reported that integration of HIV and sexual and reproductive health services and specific guidelines to support people living with HIV and their partners in planning pregnancies and managing their health is paramount [46, 52]. Another study advocated for including men in reproductive health and HIV educational efforts as they are often important decision makers and women may want their input and support [42]. In the only quantitative study included in this review, (surveys with medical providers), they reported low knowledge about HIV and reproductive health in general [50]. Only about 10% of medical providers were aware of some reproductive options for women living with HIV. Some providers openly expressed their inability to give qualified and relevant advice to women living with HIV [50]. In a qualitative study with medical providers, they reported the importance of ART counseling to ensure that women who want to get pregnant adhere but in the same study, policy makers acknowledged a lack of clinical guidelines on how to discuss ART and fertility [52]. While there is a dearth of research on perceptions about HIV, ART, and fecundity, there was a clear overall trend that providers are ill-prepared to discuss how HIV and ART affect fecundity with their patients. Discussion Despite casting a wide net with our search strategy, we found a scarcity of papers that reported perceptions about HIV or ART and fecundity in SSA. From the 12 included papers, we found some clear themes including beliefs that HIV, and one HIV prevention technology, cause infertility but perceptions around ART’s effect on fecundity were predominantly positive. There is a lack of understanding of the relationship between HIV and fecundity among both people living with HIV and providers with several calls for additional provider training and better integration of HIV and reproductive health services. Our search strategy identified a plethora of research on safe conception strategies and technologies for sero-different partners,[4, 46, 53–57] a large body of work on prevention of vertical transmission thanks to ART, [58–63] a good deal of work on fertility desires, [64–67] and of course, the basis of this paper, clear research including systematic reviews across countries showing that HIV negatively impacts fecundity, [2–4] and ART attenuates this effect [25–28]. Given that many of the research studies on HIV’s negative effect on fecundity and the protective effect of ART was published over a decade ago, we were surprised to find so few studies (and only one quantitative study) reporting on knowledge, attitudes, and perceptions of this phenomenon. The current state of the literature has been on more proximal concerns like how ART affects lifespan, preventing vertical transmission, and reducing stigma around people living with HIV having children at all. It is also important to note that many of these studies took place before ART was recommended for everyone diagnosed with HIV in 2015. Therefore, awareness around HIV, ART, and fecundity would have likely improved since then. However, policy implementation often takes years to change following guidelines. Given that, we wanted to understand if these beliefs exist for ART use. We only found one study that reported the belief that an HIV prevention technology (specifically the hormones in the PrEP ring) cause infertility [43]. And we found three studies that report the belief that ART facilitates pregnancy, [45, 47, 51] representing a promising educational strategy to emphasize among men or women living with HIV who want children in the future. In sum, while the belief that contraceptives cause infertility is a well-documented barrier to contraceptive use, the belief that ART facilitates pregnancy could be a driver for ART adherence. To our knowledge, this has yet to be included in ART adherence education nor to be tested in ART adherence programs. This study has several strengths including our multi-disciplinary team from diverse geographies and backgrounds, inclusion of both French and English studies, and an applied approach that reports recommendations for future interventions and research. This study also has some limitations that should be taken into consideration while interpreting the results. Specifically, although we used a systematic, transparent, and replicable process to identify all relevant research from one authoritative and comprehensive biomedical and health sciences literature database, we did not search databases outside of PubMed or conduct a grey literature search. We made this decision after our initial search and discussions with HIV and infertility experts that given the paucity of research in this field, this was not warranted. Additionally, due to the scoping nature of our research questions, we did not conduct a quality assessment of each paper included in the review. Finally, our search is limited to SSA, so findings may not be relevant to other regions. However, focusing on this region is also a strength given the high prevalence of women of reproductive age living with HIV in this continent. Next steps from this work point to the importance of conducting qualitative research with men and women living with HIV to better understand their perceptions of this phenomenon and their influence on behaviors. Given that several studies reported a lack of training and perceived stigma around preconception counseling, research to better understand HIV providers’ knowledge and current practices is also warranted. Furthermore, given that knowledge, beliefs, and attitudes change over time, future research could develop a module for insertion within a nationally representative population-level survey and then measure changes in perceptions about HIV, ART, and fecundity. This approach would enable researchers to understand which factors are associated with these beliefs and how beliefs differ by geography. Finally, the cultural importance of motherhood and childbearing in SSA cannot be underestimated. Raising awareness that ART can improve fecundity among people living with HIV who would like to have children in the future, could be the difference between adhering to ART or not. A particularly poignant time could be when or soon after adolescent girls and young women are diagnosed with HIV. Having the knowledge that their immediate actions, (regular ART adherence), could have long term benefits for their fecundity and not taking it could have negative impacts, could make a population level difference in ART adherence across SSA. Oftentimes, people are motivated to change behavior and improve their health for the sake of others, and in this case, their future children. In conclusion, the results of this review provide important information to inform programs that aim to raise awareness among women, men, their providers, and social networks about the relationship between HIV, ART, and fecundity to both increase ART adherence and help people living with HIV build their families. Perhaps a light touch, low-cost intervention could be warranted either using patient to provider education, technology, or mass communication. To our knowledge, this approach has not been tested and could help get us closer to the “95-95-95” goal (people living with HIV will know their status, receive ART, and achieve viral suppression) to both prevent transmission and treat HIV. Abbreviations HIV - human immunodeficiency virus ART - antiretroviral therapy PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-Analyses Declarations Ethics approval and consent to participate Not applicable Availability of data and materials Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. Funding Removed for blind review. Authors' contributions (masked for blind review) XX, XX, and XX conceptualized the systematic scoping review. XX, XX, and XX screened all papers and conducted the full text review, XX wrote the initial draft of the paper. XX, XX, XX, XX, and XX provided valuable feedback and edits on the initial draft. All authors read and approved the final version. 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AIDS Behav . 2020;24(6):1676-1686. doi:10.1007/s10461-019-02685-4 Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Cedars","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Marcelle","middleName":"I.","lastName":"Cedars","suffix":""},{"id":484204012,"identity":"4c9868c1-3b4d-4115-a0cc-128895188be9","order_by":6,"name":"Kenneth Ngure","email":"","orcid":"","institution":"Jomo Kenyatta University of Agriculture and Technology","correspondingAuthor":false,"prefix":"","firstName":"Kenneth","middleName":"","lastName":"Ngure","suffix":""},{"id":484204013,"identity":"965fa5ed-fddc-4939-9e8f-5133718860cf","order_by":7,"name":"Monica Gandhi","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Monica","middleName":"","lastName":"Gandhi","suffix":""}],"badges":[],"createdAt":"2025-07-11 17:39:31","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7103751/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7103751/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86670379,"identity":"b32e64dd-b558-4bd4-b8b6-7c46be4f68df","added_by":"auto","created_at":"2025-07-14 11:27:37","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":354987,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram for study selection process\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7103751/v1/f52f65a68ab9b759634040f6.jpeg"},{"id":86672884,"identity":"56253bca-1fbe-4989-a942-d1fce62025c0","added_by":"auto","created_at":"2025-07-14 11:43:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1414621,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7103751/v1/5783ac95-3159-4071-b589-79c5d495f868.pdf"},{"id":86670374,"identity":"dad92436-c361-46f2-b389-d3e3a35a58bf","added_by":"auto","created_at":"2025-07-14 11:27:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17218,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7103751/v1/49229e9e342995b1620acec1.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003ePerceived effect of HIV status and ART treatment on fecundity in sub-Saharan Africa: Findings from a systematic scoping review\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eA 2022 World Health Organization (WHO) meta-analysis reported that in sub-Saharan Africa (SSA), 1 in 5 couples experience infertility—the inability to conceive after 12 months of unprotected sex [1]. Women living with HIV face even higher infertility and subfertility (an extended period of unwanted non-conception without confirmed infertility) rates than their HIV-negative counterparts [2–5]. A study using Demographic Health Survey data including objective biomarkers of HIV status from eleven African countries found that women living with HIV had a 25% average reduction in fecundity [3]. Moreover, among a subset of women who unsuccessfully tried to become pregnant for three months, women living with HIV had half the odds of subsequently becoming pregnant compared to women without HIV [3]. A 2021 study from South Africa corroborated this finding, reporting that women with high viral loads (a marker for antiretroviral therapy [ART] non-adherence) are more than twice as likely to miscarry than women who are virally suppressed [6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral factors contribute to elevated infertility and subfertility risk among women living with HIV, largely related to immune and endocrine system dysfunction. For example, women living with HIV often have increased rates of prolonged anovulation and amenorrhea, and increased risk and severity of other co-infections, such as chlamydia and gonorrhea, which can lead to pelvic inflammatory disease (PID), a leading cause of tubal factor infertility [7–11]. HIV also affects male fertility, but the sperm abnormalities found in HIV patients are poorly understood, since both the virus and treatment (ART) can cause changes [12,13]. Despite the varied effects, men on ART show improvement in sperm quality after six months on ART [14].\u003c/p\u003e\n\u003cp\u003eInfertility and HIV combined can create a high burden of distress for women in general, but especially in SSA, where motherhood often defines a woman’s worth [15–17]. A 2024 scoping review on the social impacts of infertility and HIV found that both an HIV diagnosis and infertility were stigmatizing experiences for women who wanted children, but the stigma of infertility had a greater negative impact on women than an HIV diagnosis [18]. A 2025 qualitative study among sero-different couples in Uganda found that having more children helped avoid infertility stigma and was prioritized over HIV prevention [19]. Research among women living with HIV in SSA highlights the normative perception that having children makes you a “full person” [20] and infertility in this setting is responsible for significant social, psychosocial and economic costs [21]. Our prior work in Kenya illuminated the family and societal pressure to have children soon after marriage to prove one's fertility and as part of the spoken or unspoken contract of marriage [17].\u003c/p\u003e\n\u003cp\u003eFortunately, advances in ART allow women with HIV, including women in sero-different relationships, to safely conceive and prevent vertical transmission [22, 23]. In 2015, the WHO began recommending universal ART at HIV diagnosis, regardless of CD4 count or other indicators to improve health status and prevent transmission [24]. Before this, pregnant women were automatically ART eligible but otherwise healthy women were not ART-eligible pre-conception. ART suppresses the virus, making it undetectable—and untransmittable (“undetectable = untransmittable”) [22]. Since this shift, studies show that women on ART have higher fertility rates [25]. A 2016 review found that ART improves women’s fecundity after about a year of consistent use [26]. As ART access expands, the fertility gap between HIV-positive and HIV-negative women continues to close [25, 27, 28]. But ART adherence challenges persist; only 78% of people living with HIV in Eastern and Southern Africa are virally suppressed [29]. Factors influencing adherence are complex, intersectional, and likely gender-specific across settings. Some notable barriers include HIV stigma and confidentiality concerns, lack of family and community support, physical, economic, and emotional stress, depression, alcohol or drug use [30, 31]. Given the multi-level barriers, a multi-faceted approach is needed to address adherence but thus far, awareness around HIV, ART, and fertility has not been utilized as a potential ART driver.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo promote ART adherence and help women and couples reach their family building goals, we need a better understanding of how people perceive the link between HIV, ART, and fecundity. To our knowledge, there has been no systematic or scoping review of people’s perceptions of the relationship between HIV, ART, and fertility/fecundity performed to date. This systematic scoping review fills that gap, collating targeted valuable information from across the literature to inform ART adherence efforts and, ultimately, to help couples living with HIV reach their family building goals. Without attention to this area of research, we may be missing salient and potentially effective messages to improve ART adherence. \u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eOur scoping review methodology is informed by the Arksey and O\u0026rsquo;Malley [32] and Levac\u0026nbsp;et al frameworks which outline the required steps to complete a rigorous review [33] and is in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) guidelines [34]. We opted to conduct a systematic scoping review rather than a systematic review due to the wide-ranging nature of our questions and the fact that our findings are intended to identify research gaps and synthesize the literature rather than guide medical or policy decisions [35]. Given the absence of previous reviews, a scoping review is an appropriate first step to explore the existing literature on perceptions of HIV, ART, and fertility [35].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObjectives\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe objective of this scoping review is to map the literature on people\u0026rsquo;s \u003cem\u003eunderstandings and beliefs\u0026nbsp;\u003c/em\u003eof; 1) the relationship between HIV and fecundity, and 2) the \u003cem\u003eeffectiveness of ART\u003c/em\u003e in reducing HIV\u0026apos;s adverse impact on fecundity. Additionally, we aimed to uncover gaps in the literature and to document suggestions for areas of intervention to increase awareness around how HIV and ART affect fecundity. To achieve these objectives, our review targets the following primary and secondary research questions:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Research Questions:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWhat are people\u0026rsquo;s understandings of the relationship between \u003cem\u003eHIV and fecundity\u0026nbsp;\u003c/em\u003ein sub-Saharan Africa?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWhat are people\u0026rsquo;s understandings of the relationship between \u003cem\u003eART and fecundity\u003c/em\u003e in sub-Saharan Africa?\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Research Questions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWhat are the authors\u0026rsquo; recommendations for interventions to raise awareness around how HIV and ART affect a couple\u0026rsquo;s ability to conceive?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWhat are the research gaps for future research?\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eKey Concepts\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this scoping review, we are referring to fecundity as a woman\u0026rsquo;s ability to biologically conceive [3]. Fertility refers to the number of children that women have and fertility preferences are the number of children that women want to have. Sub-fertility refers to an extended period of unwanted non-conception without confirmed infertility (often defined as not having conceived within six months of attempted conception) [4]. Given that they are often used interchangeably, and we are interested in beliefs, norms and perceptions, we used all terms in our search but during screening and full text review, we only included papers that refer to perceptions about HIV or ART and fecundity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Sources and Management\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe reviewed PubMed and all data and articles were managed within Zotero reference manager (Fairfax, Virginia, USA) and Covidence systematic review (Melbourne, Victoria, Australia) softwares. After our initial search and discussions with HIV and infertility experts, we decided not to search databases outside of PubMed or conduct a grey literature review given the dearth of research at this intersection.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSearch strategy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe worked collaboratively with a medical librarian at (masked for blind review) with training and experience in systematic and scoping reviews to design our search strategy using an iterative process that follows an established search method. We employed a three-step search strategy for identifying published studies. First, we conducted a preliminary search in PubMed to identify key articles on our topic and begin the process of term harvesting, described below. From these key articles, we extracted text words and MeSH terms from titles, abstracts and author-supplied keywords and built a comprehensive list of keywords and controlled vocabulary terms, to inform our search strategy development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe search strategy was developed in PubMed, using controlled vocabulary (eg, MeSH, Emtree, thesaurus terms) where databases allow. The medical librarian reviewed multiple iterations, including the final search strategy, and discussed with authors which terms to add or remove to optimize the search for our research questions, using the Peer Review of Electronic Search Strategies guidelines [37]. Third, the reference lists of all included reports and articles were searched to identify any additional eligible studies (n=9 additional studies were included).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe search strategy combined three main concepts: 1. HIV/ART; 2. fecundity/fertility/infertility/subfertility; and 3. knowledge/attitudes/beliefs/perceptions. Boolean logic was applied by combining similar key words and controlled vocabulary. Table 1 shows our strategy which produced 1,984 results:\u003c/p\u003e\n\u003cp\u003eTable 1 Search Strategy\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e(HIV [tiab] OR \u0026quot;HIV\u0026quot;[Mesh] OR \u0026ldquo;Human immunodeficiency virus\u0026rdquo; [tiab] OR \u0026ldquo;HIV infections\u0026rdquo; [tiab])\u003c/p\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003cp\u003e(attitudes [tiab] OR attitude [tiab] OR belief [tiab] OR beliefs [tiab] OR knowledge [tiab] OR perception [tiab] OR perceptions [tiab] OR perspectives [tiab] OR understand [tiab] OR understanding [tiab] OR idea [tiab] OR ideas [tiab])\u003c/p\u003e\n \u003cp\u003eAND\u003c/p\u003e\n \u003cp\u003e(fecundity [tiab] OR fecund [tiab] OR conceive [tiab] OR childbearing [tiab] OR fertility [tiab] OR fertile [tiab] OR subfertile [tiab] OR subfertility [tiab] OR reproductive [tiab] OR pregnancy [tiab] OR pregnant [tiab])\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAND\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(\u0026ldquo;sub-Saharan Africa \u0026rdquo; [tiab] OR Africa [tiab] OR Angola [tiab] OR Benin [tiab] OR Botswana [tiab] OR \u0026ldquo;Burkina Faso\u0026rdquo; [tiab] OR Burundi [tiab] OR \u0026ldquo;Cabo Verde\u0026rdquo; [tiab] OR Cameroon [tiab] OR \u0026ldquo;Central African Republic\u0026rdquo; [tiab] OR Chad [tiab] OR Comoros [tiab] OR Congo [tiab] OR \u0026ldquo;C\u0026ocirc;te d\u0026apos;Ivoire\u0026rdquo; [tiab] OR \u0026nbsp;[tiab] OR Djibouti [tiab] OR Equatorial Guinea [tiab] OR Eritrea [tiab] OR Eswatini [tiab] OR Ethiopia [tiab] OR Gabon [tiab] OR Gambia [tiab] OR Ghana [tiab] OR Guinea [tiab] OR \u0026ldquo;Guinea-Bisub-Saharan Africa u\u0026rdquo; [tiab] OR Kenya [tiab] OR Lesotho [tiab] OR Liberia [tiab] OR Madagascar [tiab] OR Malawi [tiab] OR Mali [tiab] OR Mauritania [tiab] OR Mauritius [tiab] OR Mayotte [tiab] OR Mozambique [tiab] OR Namibia [tiab] OR Niger [tiab] OR Nigeria [tiab] OR Rwanda [tiab] OR \u0026ldquo;Sao Tome and Principe\u0026rdquo; [tiab] OR Senegal [tiab] OR Seychelles [tiab] OR \u0026ldquo;Sierra Leone\u0026rdquo; [tiab] OR Somalia [tiab] OR \u0026ldquo;South Africa\u0026rdquo; [tiab] OR \u0026ldquo;South Sudan\u0026rdquo; [tiab] OR Sudan [tiab] OR Togo [tiab] OR Tanzania [tiab] OR Uganda [tiab] OR Zambia [tiab] OR Zimbabwe [tiab])\u003c/p\u003e\n \u003cp\u003eNOT\u003c/p\u003e\n \u003cp\u003e(\u0026ldquo;sero-discordant\u0026rdquo; NOT discordant [tiab])\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWe conducted the search on November 1 2024, and included articles from 2000 through 2024. We chose to include papers from the year 2000 because beliefs and information spread from person to person so someone living with HIV now may be influenced by what others in their community (e.g., their grandparents, in-laws, friends, etc.) believed about how HIV and ART affect fertility from years ago [38]. Additionally, while the WHO\u0026rsquo;s recommendation for universal ART began in 2015, implementation of these guidelines varied across countries [39]. Therefore, we included studies published up to 15 years prior to the shift in WHO ART recommendations. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInclusion and exclusion criteria\u003c/p\u003e\n\u003cp\u003eInclusion and exclusion criteria for selection of eligible studies was developed using the population, concept, context elements proposed for scoping reviews by the Joanna Briggs Institute (Table 2) [40]. No limits were placed on study design; we included both quantitative and qualitative methods. We included studies that took place in, or report on findings from SSA, written in English or French.\u003c/p\u003e\n\u003cp\u003eTable 2 \u003cstrong\u003ePopulation, concept and context for identification of eligible studies\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCriteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73.0769%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73.0769%;\"\u003e\n \u003cp\u003eAny perceptions including of people living with HIV, the providers who care for them, or anyone else (e.g., their social networks including community members, friends, family, and anyone in the general population).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConcept\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73.0769%;\"\u003e\n \u003cp\u003eBoth quantitative and qualitative research around HIV, ART, and fertility.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73.0769%;\"\u003e\n \u003cp\u003eSub-Saharan Africa; articles written in English or French.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eStudy selection\u003c/p\u003e\n\u003cp\u003eThree reviewers (masked for blind review) participated in the screening and full text review. Two of the reviewers are from U.S. institutions and one reviewer is from a Kenya based institution. Their backgrounds range from public health to anthropology to health services research. Reviewers independently screened titles and abstracts of all articles (two reviewers per article), followed by full-text screening and data extraction. Reviewers met weekly during the abstract review process to discuss challenges and ambiguities related to study selection. Study screening progress is documented in a modified PRISMA flow chart (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExtraction of results\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter the search was completed, all citations were imported to Covidence for management and screening. Duplicates were removed and additional records were identified through hand searching including reviewing the references for included papers. Next, a sequential screening process was implemented. First, we reviewed titles and abstracts for inclusion to identify all potentially relevant reports, then we reviewed full texts for definitive classification of inclusion or exclusion. \u0026nbsp;We used a charting table to record information from each publication. Charting is a method for synthesizing and interpreting qualitative data by sifting, sorting, and analyzing material according to key issues and themes. Table 3 below, \u0026ldquo;Characteristics and findings of included studies related to perceptions about HIV or ART and fecundity\u0026rdquo; is the final charting table that reports on results related to our research questions only. We excluded articles that ultimately did not align with our inclusion criteria after full text review leaving 12 articles in the review. Due to the scoping nature of our research questions, we did not appraise the quality of the papers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData synthesis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe present the findings from our scoping review in both a table format with year of the literature, countries of origin, research methods, etc. following the general format of our charting table (Table 3) and in a narrative format. Reviewers thematically analyzed the data according to our two primary and two secondary research questions. Additional content experts (a medical doctor who cares for people living with HIV and a social scientist who conducts HIV and ART adherence research in Kenya) also contributed to interpretation during this step. We created an excel document with all papers where we conducted the full text review (n=32) and described in detail the methods and findings according to each of the four research questions. We highlighted the findings that were relevant to our research questions so that we could easily determine which to include in the final review and which to discuss during meetings. Three reviewers (co-authors ES, NW, and JA) read through the papers to ensure that we could break a tie if two researchers disagreed whether to include a study or not. We met weekly during this process to discuss findings within the charting table and ultimately agreed on the twelve papers listed below.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFigure 1 shows the PRISMA flow diagram for study selection process. We initially identified 1981 papers. In the first stage, three duplicates were removed. A total of 1955 were ineligible and nine were added, which we found through other sources, including a hand search of references. In the second stage, we conducted a full text review of 32 papers. Of the 32 studies, 20 did not meet the inclusion criteria as they were not reporting on our primary or secondary research questions but on tertiary topics such as prevention of vertical transmission, safe conception for sero-different partners, and fertility desires (see Supplemental File 1 Excluded Studies). While a total of 12 studies met our study inclusion criteria, the level of relevance to our research questions varied. All included papers referenced our phenomena but did not report in depth findings. In other words, we did not find a paper with the aim of reporting on perceptions about the relationship between HIV, ART, and fecundity illuminating a scarcity of literature on this topic.\u003c/p\u003e\n\u003cp\u003eTable 3 shows information about the selected publications. These papers use data from across sub-Saharan Africa including Uganda, Senegal, Malawi, South Africa, Zimbabwe, Kenya, Tanzania, Botswana, Ghana, and Zambia. Eleven papers were published in English, and one was published in French in a range of journals including public health, reproductive health, and HIV focused journals. The papers were published between 2009 and 2019 but nine out of twelve before 2015 when ART was recommended for all people when diagnosed with HIV regardless of CD4 count. We included eleven qualitative studies and one quantitative study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Characteristics and findings of included studies related to perceptions about HIV or ART and fecundity\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"106%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor(s)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eData collection methods \u0026amp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eparticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFindings and Recommendations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eKing et al.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(2011)\u003csup\u003e41\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eIn-depth interviews\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWomen on ART (n=29), Partners of women on ART (n=16)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eCouples commonly held the belief that HIV made them infertile. \u0026nbsp;As a result, some did not use family planning (or used inconsistently) so in several cases, pregnancy was a surprise. Both men and women associated ART with positive outcomes such as better physical and emotional health which led to increased sexual desire and ultimately pregnancy for some.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eRecommendation:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e Integrate reproductive health education and family planning services into ART programs for both men and women that focus on restoring fertility following ART initiation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e*Sow (2014)\u003csup\u003e42\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eSenegal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eRepeated semi-structured individual interviews, group interviews, participant observations.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHealthcare professionals (n=21)\u003c/p\u003e\n \u003cp\u003eHIV-negative pregnant women (n=20)\u003c/p\u003e\n \u003cp\u003eHIV-positive women (n=25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eThere were concerns about taking ART during pregnancy.\u0026nbsp;Couples sometimes seek guidance from healthcare providers or from women living with HIV who have become mothers.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAlthough all the women surveyed express fear of the negative consequences associated with having multiple pregnancies due to their HIV status, the majority do not use contraception continuously.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSocial workers seem to be more attentive to the women\u0026rsquo;s desire to have children than medical doctors. Provider counseling is often limited to the maternal \u0026quot;duty\u0026quot; or \u0026quot;responsibility\u0026quot; to prevent vertical transmission.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eRecommendations:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eIn a context where the pressure to bear children is strong, the biomedical system should be re-structured to better support women\u0026rsquo;s reproductive needs and include men in educational efforts.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eChitukuta et al.\u003c/p\u003e\n \u003cp\u003e(2019)\u003csup\u003e43\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eMalawi Uganda\u003c/p\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003cp\u003eZimbabwe\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eIn-depth interviews and focus group discussions\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHIV-negative, sexually active\u003c/p\u003e\n \u003cp\u003ewomen (n=214)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eParticipants believed that the drugs inside the vaginal ring for HIV-1 prevention, were intentionally there to cause infertility so as \u0026ldquo;to limit the Black population\u0026rdquo; resulting in fear of using it.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eUjiji et al.\u003c/p\u003e\n \u003cp\u003e(2010)\u003csup\u003e44\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eKenya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eIn-depth interviews\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePregnant women (n=9)\u003c/p\u003e\n \u003cp\u003eWomen who had delivered in the past 12 weeks (n=6)\u003c/p\u003e\n \u003cp\u003eWomen who were seeking to become pregnant (n=5)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eSome women perceived counselling to improve their CD4 cell count before trying to conceive as restrictive; they felt it could delay pregnancy and were considered tests to determine their capability of getting pregnant.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eRecommendations:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCounseling should focus on bridging the gap in knowledge between lab test results and health behaviors (like ART adherence), which could help women understand how this may affect their goals for having children.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eNduna \u0026amp; Farlane (2009)\u003csup\u003e45\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eSemi-structured interviews, focus groups and a series of participatory workshops\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBlack African women (n=78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eWomen considered their partners desires for children, especially when the partner did not have HIV or other children, which caused them some anxiety. On the one hand, they wanted to meet these desires but were wary of potential health risks.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSome participants felt that getting pregnant would be too strenuous on their bodies given their HIV diagnosis. Some expressed a fear of dying because their bodies would be \u0026ldquo;drained of nutrients\u0026rdquo; while pregnant and living with HIV. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWomen felt that ART made them fit for pregnancy as it boosted their immunity but were still worried about whether ART would help them to live long enough to raise their children. They reported that ART helped them fulfill childbearing expectations from partners and families.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCommunicating fertility desires with healthcare providers was encouraged to receive necessary counselling but women often did not seek preconception counseling/care due to stigma from providers against women living with HIV having children.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eRecommendations:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eAuthors noted that women living with HIV need to be informed about how HIV affects pregnancy outcomes and vice versa. Despite healthcare providers willingness to have fertility discussions, they often discourage women living with HIV from getting pregnant. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eSaleem et al. (2016)\u003csup\u003e46\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eTanzania\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eIn-depth interviews\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHealthcare providers (n=30),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMen with HIV (n=30)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWomen with HIV (n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eHealthcare providers felt limited in their capacity to support patients living with HIV about their reproductive health because they lacked training. They reported that they did not know specific policies or updates in national guidelines, so providers often referred these clients to other more qualified providers.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSome providers and patients reported that it was important for men and women living with HIV trying to conceive to first get their health checked though providers had different opinions about the recommended CD4 cell count before conception.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eA few providers discouraged their patients from having children due the effects of pregnancy on their health especially if they already had other children. Similarly, patients were worried that providers would discourage them from having children with some reporting that providers told them they could not have children due to their HIV status.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eRecommendations:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e Integration of HIV and sexual and reproductive health services to support people living with HIV and their partners in planning pregnancies and health management.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eSofolahan \u0026amp; Airhihenbuwa (2013)\u003csup\u003e47\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eFocus group discussions (n=4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWomen living with HIV on ART (n=35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003ePregnancy promoted adherence to ART as one participant said, \u003cem\u003e\u0026ldquo;I normally don\u0026rsquo;t take pills, but I take them for my baby.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSome women reported that healthcare providers discourage women living with HIV from getting pregnant without proper counseling.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eRecommendations:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eCapacity-building programs for healthcare workers\u0026nbsp;could ensure that providers are taking into consideration the sexual and reproductive desires of women living with HIV during counselling.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eGutin et. al (2020)\u003csup\u003e48\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eBotswana\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eIn-depth interviews\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSexual and reproductive health/HIV providers (n=10)\u003c/p\u003e\n \u003cp\u003eWomen living with HIV (n=10)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eHealthcare providers had reservations about childbearing including repeat pregnancies, among people living with HIV as they feared vertical transmission, which made women living with HIV feel unsupported and discouraged. Nevertheless, some providers felt that they should offer their clients counselling without preventing them from having children. Others however withheld information about safer conception.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eRecommendations:\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003eThere is a need to educate healthcare providers about the Undetectable=Untransmittable (U = U) campaign to uphold reproductive rights for women living with HIV and reduce transmission of HIV. Additionally, providers need comprehensive safer conception training to support couples and reduce health risks associated with HIV transmission.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eYeatman (2011)\u003csup\u003e49\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eMalawi\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eIn-depth interviews with men and women living with HIV (n=58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eMost participants believed that pregnancy would negatively impact their health due to living with HIV. In other words, pregnancy would \u0026ldquo;weaken their blood\u0026rdquo; and \u0026ldquo;make them ill\u0026rdquo; causing their HIV to progress. The belief that pregnancy is dangerous if you are living with HIV goes hand in hand with its corollary: if you avoid pregnancy, you will live longer.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eLaar (2013)\u003csup\u003e50\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eGhana\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eSurveys\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en=35 heath care workers: n=32 nurses, n=3 medical officers providing testing and counseling services to HIV patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eProviders demonstrated a high level of ignorance regarding the various reproductive options available to women living with HIV.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOnly ~10% of the providers were aware of some reproductive options for women living with HIV. A quarter would advise them to have unprotected intercourse as an option to conceive. Some of the providers openly expressed their inability to give qualified and relevant advice to women living with HIV.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThese findings suggest that patients living with HIV do not receive comprehensive information about their reproductive options.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eKastner et al. (2014)\u003csup\u003e51\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eUganda\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eIn-depth interviews\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en= 25 pregnant women receiving ART\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eWomen reported that counseling on childbearing was largely discouraging, emphasizing the risks of childbirth to their health given their HIV status. Despite perceived dangers of pregnancy while living with HIV, many women noted that social pressures to have children outweighed risks.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWhile formal pregnancy counseling was limited, peer support at clinics provided encouragement, fostering an informal network where women shared experiences.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProvider guidance on ART\u0026rsquo;s role in reducing health risks made women feel hopeful about pregnancy. ART access also increased optimism about childbearing, helping women regain a sense of normalcy, reduce stigma, and balance reproductive roles with their health and family well-being.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eRecommendations\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e: Addressing gaps in clinical counseling is crucial for integrating sexual and reproductive health programs. Supporting healthcare workers to routinely assess fertility goals can improve reproductive care by providing effective contraception for those avoiding pregnancy and safer conception counseling for those who wish to conceive. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIntegrating HIV and reproductive health services is essential to supporting desired pregnancies and prevent unintended ones. Public health messaging should target women living with HIV, healthcare providers, and communities to raise awareness about pregnancy experiences on ART and ensure informed reproductive choices.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eHarries et al., 2007\u003csup\u003e52\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eIn-depth interviews\u003c/p\u003e\n \u003cp\u003eHealth care providers (n=14)\u003c/p\u003e\n \u003cp\u003ePublic sector policy makers in the HIV field (n=12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eHealthcare providers believed that women should have a sufficiently high CD4 count and access to ART before getting pregnant. While others emphasized the importance of reproductive rights and person-centered care.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSome doctors were concerned that if healthcare providers overlooked patients\u0026apos; plans to become pregnant and did not offer proper counseling, those patients might stop their ART treatment.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMost policy makers felt that developing counseling guidelines for women who want to get pregnant while living with HIV would be valued. Without guidelines providers would continue \u0026quot;bumbling along\u0026quot; and make \u0026ldquo;ad hoc\u0026rdquo; recommendations.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003ePublished in French\u003c/p\u003e\n\u003cp\u003eOur systematic scoping review uncovered four emerging themes about\u0026nbsp;people\u0026rsquo;s understandings of the relationship between HIV, ART, and fecundity in SSA\u0026nbsp;including: (1) Beliefs that HIV and PrEP cause infertility exist but have not been well documented (two studies); (2) Perceptions that ART improves health before pregnancy motivates women to adhere and provides hope about future pregnancy (five studies); (3) Stigma from providers discourages women living with HIV from seeking preconception care (six studies); and (4) Lack of awareness among both providers and patients about the impact of HIV and ART on pregnancy (eight studies).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBeliefs that HIV and PrEP cause infertility exist but have not been widely documented\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe found a limited number of studies reporting that HIV or HIV prevention technologies (e.g., PrEP) cause infertility. Specifically, we found only two studies directly related to beliefs around HIV and fecundity [41, 43]. One study reported that couples believed that having HIV would make them infertile, so they were not using contraception [41]. Couples reported that since they were having sex without a condom and not getting pregnant, this was further evidence to corroborate this belief. When some couples subsequently did get pregnant accidentally, they were surprised [41]. We found one study about HIV prevention (the vaginal ring) and beliefs about infertility. This study uncovered the widespread belief among participants that the vaginal ring for HIV prevention causes infertility. Specifically, they believed that the drugs inside the ring had been put there deliberately to cause infertility and \u0026ldquo;to limit the Black population\u0026rdquo; [43].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo other studies were related to this topic but did not directly report beliefs around HIV and fecundity. In one study, participants living with HIV reported not using contraception but stated that \u0026ldquo;they knew they could get pregnant\u0026rdquo; [42]. Another study reported that women believed that getting pregnant would hasten the progression of their HIV diagnosis making pregnancy too dangerous in general for their health [49], but this study focused more on how pregnancy would negatively affect their HIV prognosis, not their fecundity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceptions that ART improves health before pregnancy motivates women to adhere and provides hope about future pregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, beliefs about ART were positive with women and providers noting the benefits for protecting women\u0026rsquo;s health, fecundity, and once pregnant, the baby\u0026rsquo;s health. All studies that reported on ART and fecundity noted positive perceptions around ART and pregnancy including improved physical and emotional health due to ART adherence which increased desire for sex resulting in an increase in pregnancy in some cases [41]. Studies also reported restored hope and a feeling of optimism about pregnancy [47, 51] and the sentiment that it would improve their immunity and therefore their chances of pregnancy [45, 42]. In one study, participants directly stated that ART enabled them to meet the expectations of their partners and families to bear children stating, \u0026ldquo;this pill [a reference to ART] is important to give in-laws children\u0026rdquo; [45]. The same paper reported that healthcare workers either encouraged women to take ART to improve pregnancy chances while others stigmatized or discouraged women living with HIV from getting pregnant at all.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt was not always clear if the optimism about pregnancy was linked to participant perspectives that ART increased their biological ability to conceive (their fecundity) or whether it reflected perspectives about ART preventing vertical transmission or increasing their lifespan to be able to live long enough to care for their children. Despite these positive perceptions about ART and fecundity, some participants were still concerned about whether ART would allow them to live long enough to raise their children, and providers sometimes exacerbated these fears by only recommending one child [45].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn some studies, women reported that their provider advised them to \u0026ldquo;get healthy\u0026rdquo; or improve their CD4 count via ART before attempting pregnancy [44, 46]. In one study, women reported that this felt overly intrusive as this could delay their pregnancy. They felt that the clinic was restricting them and expecting them to ask for permission to become pregnant. They felt the tests done by the clinic to decide on their capability to become pregnant unnecessary [44]. And in a study which documented medical providers perceptions, some stated that women should have a sufficiently high CD4 count and access to ART before getting pregnant, while others emphasized the importance of reproductive rights to decide on their own when they want to get pregnant [52].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStigma and lack of clear guidance from providers discourages women living with HIV from seeking preconception care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough women living with HIV can safely conceive and give birth if they adhere to ART, we found that many women felt stigma from their provider, especially if they wanted a second or third child, and this discouraged them from seeking care. Some health care workers reported being open to discussions of fertility plans but data from patients suggests that providers can dissuade women living with HIV who would like to get pregnant [45, 48). Therefore, authors report that women often do not seek preconception counseling/care due to anticipated stigma from providers that having multiple children while living with HIV is risky [45]. Some providers voiced uneasiness about repeat pregnancies, suggesting that one pregnancy was acceptable but repeat pregnancies were concerning because of health risks for the mother and transmission risks for the partner and infant. When trying to communicate these concerns, providers sometimes used language that suggested to women living with HIV that they were discouraging pregnancy [45, 46, 48]. One study reported that social workers seem to be more person-centered around women\u0026rsquo;s desire to have children than medical providers [42] presenting a potential task-shifting or training opportunity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of awareness among both providers and patients about the impact of HIV on pregnancy, highlights the need for provider training\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost of the papers in this review (8 out of 14) mentioned a lack of understanding about how HIV and ART affect fecundity. This was true for both providers and patients. Several papers mentioned a notable gap in provider training around HIV and sexual and reproductive health and a call to increase community health worker training specifically [46, 47]. Some healthcare providers felt limited in their capacity to offer their clients living with HIV counseling on safe conception and pregnancy as they were not adequately trained [46]. Authors mentioned this is critical because as previously mentioned, patients reported that some providers advise them not to have children or not to have more than one child [45, 48, 46].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne study reported, \u0026ldquo;women living with HIV require information on the impact of HIV on pregnancy outcomes and vice versa\u0026rdquo; [45]. This was common across studies; several studies reported that women believed that pregnancy would weaken their immune system thereby worsening their overall health and not getting pregnant was best for their health [45, 49]. Current HIV services for women of reproductive age do not appear to proactively address issues of pregnancy and HIV progression, need to change ART regimens when considering or while pregnant, and post-partum recovery [45]. Studies reported that integration of HIV and sexual and reproductive health services and specific guidelines to support people living with HIV and their partners in planning pregnancies and managing their health is paramount [46, 52]. Another study advocated for including men in reproductive health and HIV educational efforts as they are often important decision makers and women may want their input and support [42].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the only quantitative study included in this review, (surveys with medical providers), they reported low knowledge about HIV and reproductive health in general [50]. Only about 10% of medical providers were aware of some reproductive options for women living with HIV. Some providers openly expressed their inability to give qualified and relevant advice to women living with HIV [50]. In a qualitative study with medical providers, they reported the importance of ART counseling to ensure that women who want to get pregnant adhere but in the same study, policy makers acknowledged a lack of clinical guidelines on how to discuss ART and fertility [52]. \u0026nbsp;While there is a dearth of research on perceptions about HIV, ART, and fecundity, there was a clear overall trend that providers are ill-prepared to discuss how HIV and ART affect fecundity with their patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite casting a wide net with our search strategy, we found a scarcity of papers that reported perceptions about HIV or ART and fecundity in SSA. From the 12 included papers, we found some clear themes including beliefs that HIV, and one HIV prevention technology, cause infertility but perceptions around ART\u0026rsquo;s effect on fecundity were predominantly positive. There is a lack of understanding of the relationship between HIV and fecundity among both people living with HIV and providers with several calls for additional provider training and better integration of HIV and reproductive health services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur search strategy identified a plethora of research on safe conception strategies and technologies for sero-different partners,[4, 46, 53\u0026ndash;57] a large body of work on prevention of vertical \u0026nbsp;transmission thanks to ART, [58\u0026ndash;63] a good deal of work on fertility desires, [64\u0026ndash;67] and of course, the basis of this paper, clear research including systematic reviews across countries showing that HIV negatively impacts fecundity, [2\u0026ndash;4] and ART attenuates this effect [25\u0026ndash;28]. Given that many of the research studies on HIV\u0026rsquo;s negative effect on fecundity and the protective effect of ART was published over a decade ago, we were surprised to find so few studies (and only one quantitative study) reporting on knowledge, attitudes, and perceptions of this phenomenon. The current state of the literature has been on more proximal concerns like how ART affects lifespan, preventing vertical transmission, and reducing stigma around people living with HIV having children at all. It is also important to note that many of these studies took place before ART was recommended for everyone diagnosed with HIV in 2015. Therefore, awareness around HIV, ART, and fecundity would have likely improved since then. However, policy implementation often takes years to change following guidelines.\u003c/p\u003e\n\u003cp\u003eGiven that, we wanted to understand if these beliefs exist for ART use. We only found one study that reported the belief that an HIV prevention technology (specifically the hormones in the PrEP ring) cause infertility [43]. And we found three studies that report the belief that ART facilitates pregnancy, [45, 47, 51] representing a promising educational strategy to emphasize among men or women living with HIV who want children in the future. In sum, while the belief that contraceptives cause infertility is a well-documented barrier to contraceptive use, the belief that ART facilitates pregnancy could be a driver for ART adherence. To our knowledge, this has yet to be included in ART adherence education nor to be tested in ART adherence programs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has several strengths including our multi-disciplinary team from diverse geographies and backgrounds, inclusion of both French and English studies, and an applied approach that reports recommendations for future interventions and research. This study also has some limitations that should be taken into consideration while interpreting the results. Specifically, although we used a\u0026nbsp;systematic, transparent, and replicable process to identify all relevant research from one authoritative and comprehensive biomedical and health sciences literature database, we did not search databases outside of PubMed or conduct a grey literature search. We made this decision after our initial search and discussions with HIV and infertility experts that given the paucity of research in this field, this was not warranted. Additionally, due to the scoping nature of our research questions, we did not conduct a quality assessment of each paper included in the review. Finally, our search is limited to SSA, so findings may not be relevant to other regions. However, focusing on this region is\u0026nbsp;also a\u0026nbsp;strength given the high prevalence of women of reproductive age living with HIV in this continent.\u003c/p\u003e\n\u003cp\u003eNext steps from this work point to the importance of conducting qualitative research with men and women living with HIV to better understand their perceptions of this phenomenon and their influence on behaviors. Given that several studies reported a lack of training and perceived stigma around preconception counseling, research to better understand HIV providers\u0026rsquo; knowledge and current practices is also warranted. Furthermore, given that knowledge, beliefs, and attitudes change over time, future research could develop a module for insertion within a nationally representative population-level survey and then measure changes in perceptions about HIV, ART, and fecundity. This approach would enable researchers to understand which factors are associated with these beliefs and how beliefs differ by geography.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, the cultural importance of motherhood and childbearing in SSA cannot be underestimated. Raising awareness that ART can improve fecundity among people living with HIV who would like to have children in the future, could be the difference between adhering to ART or not. A particularly poignant time could be when or soon after adolescent girls and young women are diagnosed with HIV. Having the knowledge that their immediate actions, (regular ART adherence), could have long term benefits for their fecundity and not taking it could have negative impacts, could make a population level difference in ART adherence across SSA. Oftentimes, people are motivated to change behavior and improve their health for the sake of others, and in this case, their future children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn conclusion, the results of this review provide important information to inform programs that aim to raise awareness among women, men, their providers, and social networks about the relationship between HIV, ART, and fecundity to both increase ART adherence and help people living with HIV build their families. Perhaps a light touch, low-cost intervention could be warranted either using patient to provider education, technology, or mass communication. To our knowledge, this approach has not been tested and could help get us closer to the \u0026ldquo;95-95-95\u0026rdquo; goal (people living with HIV will know their status, receive ART, and achieve viral suppression) to both prevent transmission and treat HIV.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHIV - human immunodeficiency virus\u003c/p\u003e\n\u003cp\u003eART - antiretroviral therapy\u003c/p\u003e\n\u003cp\u003ePRISMA - Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRemoved for blind review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions (masked for blind review)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXX, XX, and XX conceptualized the systematic scoping review. XX, XX, and XX screened all papers and conducted the full text review, XX wrote the initial draft of the paper. XX, XX, XX, XX, and XX provided valuable feedback and edits on the initial draft. All authors read and approved the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCox CM, Thoma ME, Tchangalova N, et al. Infertility prevalence and the methods of estimation from 1990 to 2021: a systematic review and meta-analysis. \u003cem\u003eHum Reprod Open\u003c/em\u003e. 2022;2022(4):hoac051. doi:10.1093/hropen/hoac051\u003c/li\u003e\n\u003cli\u003eDesgr\u0026eacute;es du Lo\u0026ucirc; A, Msellati P, Yao A, Noba V, Viho I, Ramon R, Welffens-Ekra C, Dabis F. 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PhD, MSc, BSN*; Piscoya-Angeles, Patricia N. M; Edwards, Joan E; Palmieri, Patrick A. The Experience of Pregnancy in Women Living With HIV: A Meta-Synthesis of Qualitative Evidence. \u003cem\u003eJ Assoc Nurses AIDS Care\u003c/em\u003e. 2017;28(4):587-602. doi:10.1016/j.jana.2017.04.002\u003c/li\u003e\n\u003cli\u003eGarver S, Trinitapoli J, Yeatman S. Changing Childbearing Norms During an Era of ART Expansion in Malawi, 2009 to 2015. \u003cem\u003eAIDS Behav\u003c/em\u003e. 2020;24(6):1676-1686. doi:10.1007/s10461-019-02685-4\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of California, San Francisco","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV, fertility, fecundity, sub-Saharan Africa, scoping systematic review","lastPublishedDoi":"10.21203/rs.3.rs-7103751/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7103751/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Advances in antiretroviral therapy (ART) enable women living with HIV to safely conceive and give birth without vertical transmission. However, in sub-Saharan Africa, 1 in 5 couples experience infertility and women living with HIV face even higher rates. Several longitudinal studies show that ART and virologic suppression improve fertility/fecundity, yet this benefit is often overlooked in ART adherence education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThe objective of this scoping review is to map the literature on people’s understandings and beliefs of; 1) the relationship between HIV and fecundity, and 2) the effectiveness of ART in reducing HIV's adverse impact on fecundity. We also documented suggestions for interventions to raise awareness around how HIV and ART affect fecundity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design:\u003c/strong\u003e We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct a scoping systematic search of English and French literature in sub-Saharan Africa from 2000–2024 with keywords related to HIV, ART, and fecundity/fertility. Three independent reviewers screened texts, read a subset of full texts, and used a charting table to summarize results and identify emerging themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrincipal Findings:\u003c/strong\u003e Of 1,981 sources identified, only 12 met our inclusion criteria. Most did not explicitly examine perceptions of HIV, ART, and fecundity but related topics. Despite the scarcity of research, we uncovered the following themes: (1) Beliefs that HIV and PrEP cause infertility exist but have not been widely documented; (2) Perceptions that ART improves health before pregnancy motivates women to adhere and provides hope about future pregnancy; (3) Stigma from providers discourages women living with HIV from seeking preconception care; and (4) Lack of awareness among providers and patients about the impact of HIV on pregnancy, highlights the need for provider training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions \u0026amp; Implications for Policy and Practice:\u003c/strong\u003e Research on perceptions of HIV, ART, and fecundity in sub-Saharan Africa is sparse despite evidence that HIV reduces fecundity while ART increases the likelihood of pregnancy. Given the cultural importance of motherhood and the stigma associated with infertility in sub-Saharan Africa, addressing this gap could improve ART adherence and help couples living with HIV build their families.\u003c/p\u003e","manuscriptTitle":"Perceived effect of HIV status and ART treatment on fecundity in sub-Saharan Africa: Findings from a systematic scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 11:27:32","doi":"10.21203/rs.3.rs-7103751/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"17292b74-d66c-42ea-bad1-7218a6759d75","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T11:27:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 11:27:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7103751","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7103751","identity":"rs-7103751","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}