Table 2 Contraceptive preferences and childbearing decisions among PLHIV

Preferred contraceptive methods

· Largely condoms: easy to use, accessible and do not affect their fertility

· Condoms most preferred: easy to use, cheap and easy to access; limited side effects; prevent pregnancy and HIV transmission (men who fear to disclose their HIV status can use them under the pretext of FP)

· Some preferred to abstain

· Some women liked injectables, implants: no challenges with remembering to take pills daily, do not like to use or cannot tell partners to use condoms (limit sexual pleasure); can use without telling their partners or asking their permission

· Fear pills, injectables and other long-term methods because they can prevent them from having children in future

Challenges/experiences with contraceptives

· Education on FP is limited; providers focusing more on adults

· Intrauterine devices and implants were not easily accessible and were expensive

· Challenges with accessing FP information; not aware of options and side-effects

· Injectables available but expensive

· Fear to ask providers for information if providers do not initiate discussion

· Limited education on some methods (e.g. Intrauterine devices; implants)

· Pills: concerns about pill burden and remembering to take them

· Side effects with pills and injectables noted by both men and women: abdominal complications, prolonged periods, infertility and child abnormalities; weight problems, high blood pressure, heart palpitations, and sleeplessness

· Mixed feelings about vasectomy among men

· Men felt providers focused more on women

· Providers focused more on PLHIV who had initiated ART

Challenges with accessing contraceptives at the clinics and other facilities

· Cost of the contraceptives high

· Mulago: busy clinic and long waiting time (separate desk/provider for FP)

· NHC: some of the PLHIV do not go to the facilities where they are referred for contraceptives; challenges disclosing their HIV status to another set of providers; ‘Moon beads’/rhythm method that is talked about at the clinic unreliable

Decisions to have children

· All want to have children; at least one/feared dying without children

· All want to have children; feel it is not good to have one child/unfair to the child

· Considerations: have few children or none/cultural expectations to have large families; have only boys or only girls; male child to have an heir; getting into a new sexual relationship/to strengthen relationship; pressures from family members and community (to be accepted); HIV status of the sexual partner; ability to care for more children

Decision not to have children

· Health status (transient issue)

· Sero-discordance/concerns about infecting sexual partner

· Already have several children

· Health status (transient issue)

Information and support given by providers on childbearing: client perspectives

· Same issues as adults

· Focusing more on contraceptives

· Not enough attention to child spacing and number of children they want to have

· Not addressing fertility decisions and support for those who want to have children

Attitude and support from HCWs in relation to childbearing: Client perspectives

· Desired to have more guidance on childbearing

· Providers talk about PMTCT services

· Counselors were supportive and asked them to be open up about their plans to marry and have children

· Health status: providers emphasized need to have high CD4 count; adherent to ART

· Noted gaps in information for those who want to have children/told to use condoms all the time and not clear how they can conceive

· Mulago: all participants felt providers were supportive

· NHC: divided about support from providers (some felt providers had negative attitude towards childbearing among PLHIV)

Health workers’ voices

· Need to expand SRH services to include cervical cancer screening

· Support for PLHIV who want to have children not comprehensive enough and needs improvement

· NHC providers noted gap with not providing FP supplies: suggested formal referral mechanism since their policy does not allow contraceptives on site

· All felt PLHIV had a right to have children and needed support: need to be clinically stable and have a high CD4 count; should be on ART; should use PMTCT services

· More sympathetic to those who have no children (e.g. adolescents); those who have children should not get more