Prevalence and factors associated with fertility desires among HIV-positive MSM

ABSTRACT

The National surveillance data showed that homosexual transmission played a considerable role in new HIV infections in China. The emphasis on antiretroviral therapy and prevention of mother-to-child transmission provided chances for reproduction among people living with HIV/AIDS. Issues of fertility desire have a paucity of data among HIV-positive men who have sex with men (MSM). This cross-sectional study has assessed fertility attitudes and associated factors, as well as the reproductive knowledge among HIV-positive MSM. Analysis was mainly based on the multinomial regression model. The study included 129 participants, and almost all of the participants (96.1%) were between 18 and 30 years old and 82.2% of them were single. About 35.6% expressed a fertility desire. MSM without siblings tended to have fertility desire (OR = 0.236, 95%CI: 0.078∼0.712, p = 0.010). Surrogacy (36.4%) was the most desired method among the 86 respondents who had the desire or did not make a decision. While the accuracy of the reproductive knowledge was only 69.6%. In summary, we recommend that providers offer much more professional information and develop assisted reproductive technology to meet the reproductive aspirations of HIV-positive MSM.

KEYWORDS:

• HIV
• MSM
• fertility desire

Introduction

Fertility desire is the natural phenomenon of any men and women at the age of fertility, in cases where people living with HIV/AIDS (PLHIV) are the same as any individual (Tilahun Wassie et al., 2022). The particularity of the transmission route suggests that not considering their fertility desire may present additional risks of HIV transmission. It implies that more attention should be paid to reproductive health on PLHIV, which has a big impact on our society and the next generation. In recent years, most studies or investigations have focused on the need for safer conception strategies for HIV-positive women or serodiscordant couples (Friedman et al., 2016). The availability of antiretroviral therapy (ART), and prevention of mother-to-child transmissions such as pre-exposure prophylaxis (PrEP), vaginal self-insemination, sperm washing, or other methods offers opportunities to conceive (Baeten et al., 2016; Mmeje et al., 2012), which have positive effects on fertility intentions among PLHIV (Guo et al., 2022). There is a paucity of data on the prevalence of fertility desire among HIV-positive men who have sex with men (MSM).

Dr. Li has estimated that there are about 39 million to 52 million homosexuals based on previous studies in China, with males accounting for a larger proportion (Li, 2002). Among the newly reported HIV infections in China in 2021, male homosexual transmission accounted for 83.8%. The reproductive problems of MSM, especially HIV-Positive MSM, should be paid more attention.

Most of the MSM in China community is still struggling with whether to “come out” to relatives. Wang has mentioned in his research that Chinese MSM identify with their homosexual behavior but do not “come out” (gaining sexual identity identification). At present, Chinese same-sex marriage has not been recognized by legislation, which may lead them to enter into heterosexual marriage (Wang, 2011). In Wei's study of middle-class MSM in Shanghai, heterosexual marriage is the result of self-selection, mainly due to the deep internalization of heterosexual orthodoxy (Wei, 2010).

With the development of The Times and the continuous progress of society, the number of MSM who choose to disclose their identities is increasing. Chinese AIDS prevention experts and sociologists have pointed out that homosexuals hope that their sexual orientation could be legally protected, and hope that the law could give same-sex marriage legitimacy (Wu, 2022).

Men's biological structure determines that their reproductive needs must rely on women. MSM can fulfill their fertility desire by marriage in the form of a woman or by having sex with a woman who is willing to bear a child, but it is not easy to implement due to emotionally difficult to accept. In terms of assisted reproductive technology, there are three common ways artificial insemination, test-tube baby, and surrogacy. In addition to adoption, if they want to conduct assisted reproductive technology to have a child, as long as it is in line with the interests of the child and does not harm the interests of third parties, it is ethically permissible, and artificial insemination is medically feasible, but surrogacy is currently prohibited in China, and artificial insemination and test-tube baby still rely on the mother (Cheng, 2014). So, in this special group of MSM, there still was a large difficulty in achieving fertility.

The investigation of fertility desire may have a certain social role in promoting the realization of the reproductive rights of MSM in the future. One study on community providers reported infrequent communication with male patients with HIV about their reproductive plans, especially in MSM (Short et al., 2021). Male-to-male homosexual transmission has become an important HIV transmission route and plays a considerable role in new HIV infections in China ( Hao et al., 2014; Zheng, 2018). A study based on nine consecutive cross-sectional surveys in Beijing, China has shown a rising trend in HIV prevalence among MSM, from 5.0% in 2009 to 6.9% in 2018 (Chen et al., 2018). On the other hand, a part of HIV-positive MSM in China may hide their true sexual orientation for fear of being discriminated against and have a marriage of convenience with females to have children, which might be harmful to women (Duan et al., 2021). As the social and economic developments, some HIV-positive MSM begin to value their true thoughts and want to achieve single fertility.

So, it is necessary to understand the reproduction of willingness and knowledge of reproduction among HIV-positive MSM to provide better guidance and promotion for reproductive health-related services.

Methods

Study population

The study population consisted of homosexual men (≥ 18 years) receiving ART at the antiretroviral treatment clinic who were voluntarily recruited between October 2020 and August 2021 in the ART clinic of Beijing Ditan Hospital, which is the National Medical Center for Infectious Diseases and the first designated medical institution to carry out the ART in China. The hospital is serving an HIV-positive population of over ten thousand. The antiretroviral therapy clinic operates daily clinical consultations, laboratory tests, and antiretroviral drugs. Patient support groups, case manager counseling, and testing was also available.

Study design and data collection

This study used a cross-sectional design and participants were recruited using convenience sampling from the pool of potential participants during routine ART follow-ups. The questionnaires were conducted by a frequently-used electronic platform, which had advantages for privacy-protecting and data management. The questionnaire's two-dimension code was stuck to the wall of the outpatient consultation area. The contents of the questionnaire and the respondents who were allowed to fill in were explained next to the two-dimensional code: The respondents were unmarried or serodiscordant family members, and the questionnaire was a fertility desire survey, which could be filled out voluntarily by scanning the code. At the same time, at the beginning of the questionnaire, the intention of this survey was explained that this was a voluntary survey and did not involve any personal privacy information.

The questionnaire was constructed based on discussions involving a team of healthcare providers in mental health, social work, and clinicians. It mainly comprised sociodemographic items, such as age, educational level, marriage (the marital status mentioned in this article referred to being married to a woman), number of siblings, average incomes, and related medical insurance. Also, each respondent provided information about the fertility desire and knowledge about reproduction. The fertility desire was assessed using the following question: “Do you want to have another child at the present?” The possible responses were “yes”, “Did not make a decision”, or “no”.

Statistical analysis

Median and inter-quartile range (IQR) were used to describe numeric variables. Categorical data were summarized as frequencies and percentages. At the bivariate level, Pearson’s ${\chi }^2$ test was used for the comparison of frequencies. Multinomial logistic regression was used to explore the factors associated with fertility desire, and adjusted odds ratios (ORs) and 95% CIs were computed using the Enter approach. The level of significance in this study was set at a p-value <0.05. Data were analyzed using R studio 4.2.1 (2022-06-23) for macOS.

Results

Participant characteristics

A total of 154 questionnaires were collected, among which 151 were male and 129 were infected by homosexual sex behaviors. The study finally included 129 participants who had sex with men. The median age for participants was 26(23, 30) years, almost all of them (96.1%) were between 18 and 30 years old. More than 50% of the participants were diagnosed between 2018 and 2020, and most of them (65.9%) were mainly undergraduate education. Meanwhile, 82.2% of them were single, and more than 80% had stable incomes. See Table 1 for a description of the characteristics of the sample.

Table 1. Social characteristics of HIV-positive MSM in different fertility desire groups [n (%)].

Variables	Total	Fertility desire			p
		Yes	No	Did not make a decision
Total	129	46(35.6)	41(31.8)	42(32.6)
Year of diagnosis					0.692
Before 2014	26(20.2)	7(15.2)	11(26.8)	8(19.1)
2015–2017	31(24.0)	13(28.3)	9(21.9)	9(21.4)
2018–2020	72(55.8)	26(56.5)	21(51.2)	25(59.5)
Age (Years) Median (IQR)	26(23, 3)	26(24, 3)	28(23, 3)	25(23.3)	0.446
18–30	124(96.1)	45(97.8)	38(92.7)	41(97.6)
Others	5(3.9)	1(2.2)	3(7.3)	1(2.4)
Educational level					0.041
≤ High school	31(24.0)	9(19.5)	11(26.8)	11(26.2)
Bachelor	85(65.9)	27(58.7)	28(68.3)	30(71.4)
Master or above	13(10.1)	10(21.7)	2(4.9)	1(2.4)
Marriage					0.032
Single	106(82.2)	38(82.6)	29(70.7)	39(92.9)
Married	20(15.5)	7(15.2)	11(26.8)	2(4.8)
Divorced	3(2.3)	1(2.2)	1(2.4)	1(2.4)
Number of siblings					0.017
0	46(35.7)	24(52.2)	10(24.4)	12(28.6)
1	32(24.8)	12(26.1)	9(21.9)	11(26.2)
>1	51(39.5)	10(21.7)	22(53.7)	19(45.2)
Census register city					0.404
Beijing	19(14.7)	9(19.6)	6(14.6)	4(9.5)
Other Cities	110(85.3)	37(80.4)	35(85.4)	38(90.5)
Average income (RMB)					0.113
< 5000	44(34.1)	10(21.7)	20(48.8)	14(33.3)
< 10000	39(30.2)	15(32.6)	10(24.4)	14(33.3)
≥10000	46(35.7)	21(45.6)	11(26.8)	14(33.3)
Have stable income					0.308
Yes	106(82.2)	41(89.1)	32(78.1)	33(78.57)
No	23(17.8)	5(10.9)	9(21.9)	9(21.43)
Subsistence allowance					0.815
Yes	8(6.2)	2(4.4)	3(7.3)	3(7.1)
No	121(93.8)	44(95.6)	38(92.7)	39(92.9)

Prevalence and factors associated with fertility desire

Of the total 129 participants in this study, about 35.6% (46/129) of the participants expressed a fertility desire, 31.8% (41/129) without fertility desires and 32.6% (42/129) were not sure if they wanted to have kids. The bivariate level Chi-square test results showed that there were distribution differences in fertility intention among MSM with different characteristics. Fertility desire was associated with the educational level, marital status, as well as number of siblings (p < 0.05). The master’s degree or above HIV-positive MSM tended to have fertility intentions. There was a higher percentage (75.6%, 31/41) of fertility desire in people who had more than one sibling than those who were the only child in the family, and 52.2% of the participants who had the fertility desire were the only children in their family. The study also showed that the proportion of single was higher in both those who had fertility desire and those who did not know whether to have children, 82.6% and 92.9% respectively. Among those who did not intend to have children, with 70.7% being single. (See details in Table 1).

At the multinomial level, fertility desire was predicted by age, year of diagnosis, education, marriage, number of siblings, income, and subsistence allowance. We set fertility desire as the reference group. Compared with MSM who had more than one sibling, MSM with no siblings tended to have fertility intentions (OR = 0.236, 95%CI: 0.078∼0.712, p = 0.010). Similarly, participants who were not sure if they wanted to have kids compared with participants who had fertility desire, respondents with no siblings were more likely to have fertility desire compared with those with more than one sibling (OR = 0.276, 95%CI: 0.0942∼0.826, p = 0.021) (Table 2).

Table 2. Multinomial logistic regression of factors associated with fertility desires.

Fertility desire	Variables	Wald ${\chi }^2$	OR	95%CI		p
				lower	upper
No	Educational level
	≤ High school	1.844	3.58	0.57	22.53	0.174
	Undergraduate	3.276	4.69	0.88	25.02	0.070
	Graduate		ref
	Number of siblings
	0	6.571	0.24	0.08	0.71	0.010
	1	2.507	0.38	0.12	1.26	0.113
	>1		ref
	Marriage
	Single	1.131	0.53	0.16	1.71	0.288
	Married/Divorced		ref
Did not make a decision	Educational level
	≤ High school	3.326	8.47	0.85	84.25	0.068
	Bachelor	3.784	8.57	0.98	74.59	0.052
	Master or above		ref
	Number of siblings
	0	5.300	0.28	0.09	0.83	0.021
	1	1.617	0.46	0.14	1.52	0.203
	>1		ref
	Marriage
	Single	1.803	2.86	0.62	13.27	0.179
	Married/Divorced		ref

Ref: Yes.

Desired way of reproduction

This study collected the desired way of reproduction from a total of eighty-eight participants who had fertility desire (n = 46) or did not think about it well (n = 42). Surrogacy was the most desired method among MSM and nearly half (21/46, 45.6%) of MSM who had the fertility desire chose surrogacy as the desired method of pregnancy, higher than that in MSM who did not think about it well. While about seventeen percent of MSM chose to naturally conceive without protective measures (see Table 3).

Table 3. Desired way of reproduction.

Desired way of reproduction	Fertility desires
	Yes	Did not figure out	Total
Naturally conceived without protective measures	8(17.4)	7(16.7)	15(17.1)
IVF	5(10.9)	8(19.1)	13(14.8)
Sperm washing technique	7(15.2)	9(21.4)	16(18.2)
A surrogate	21(45.6)	11(26.2)	32(36.4)
Others (including monitoring ovulation and conception without protective measures; having sex after puncturing the condom; injecting semen into the vagina after external ejaculation, or others)	5(10.9)	7(16.7)	12(13.6)
Total	46	42	88

It was worth noting that 17.8% of those MSM were in a current married relationship (n = 23), and 21.7% (5/23) reported having unprotected intercourse and their spouses were HIV-negative (20/23) or unaware of the HIV status (3/20). Among the twenty-three married MSM, eight of them had fertility desires, and three had not yet figured out. Among the eight MSM who had fertility intentions, four preferred natural conceptions, one participant chose pricking condoms to conception, one chose IVF (In vitro fertilization), and two participants chose surrogacy as the desired method of fertility.

Knowledge about reproduction

The participants’ knowledge of reproduction was also investigated by the self-designed scale. The Cronbach's α of the scale was 0.856 in this study. The results showed that the overall accuracy among all respondents was 69.60%, and there was no significant difference among respondents with different fertility intentions (${\chi }^2$ = 4.038, p = 0.133). Among them, Item1 (During pregnancy preparation, the positive party needs to undergo antiviral therapy and the viral load test reaches sustained inhibition (< Lower Detection Limit or less than 50 copies per milliliter), you can adopt condom-free sex.), Item5 (Women need to take folic acid for three months to prepare for pregnancy.), Item8 (If one of the women is positive and the pregnancy is successful, the child born to her should take preventive drugs within 6 h after birth, which can reduce mother-to-child transmission.), and Item9 (If the male is positive, pregnancy preparation can be carried out after antiviral treatment is carried out.) had the lower correct rate, which showed that the accuracy of Item1 was only 19.5% among those who did not want to have children, and the accuracy of Item1 was only 32.6% even for those who had fertility desire. (See Table 4 for details).

Table 4. Accuracy of reproductive knowledge among MSM [n (%)^a].

Reproductive Knowledge Scale^b		Fertility desire		Total
	Yes	No	Did not make a decision
n	46(35.6)	41(31.8)	42(32.6)	129
item1	15(32.6)	8(19.5)	14(33.3)	37(28.7)
item2	39(84.8)	31(75.6)	34(80.9)	104(80.6)
item3	37(80.4)	30(73.2)	33(78.6)	100(77.5)
item4	42(91.3)	37(90.2)	37(88.1)	116(89.9)
item5	30(65.2)	19(46.3)	20(47.6)	69(53.5)
item6	43(93.5)	38(92.7)	38(90.5)	119(92.3)
item7	41(89.1)	36(87.8)	36(85.7)	113(87.6)
item8	27(58.7)	22(53.7)	20(47.6)	69(53.5)
item9	21(45.6)	21(51.2)	20(47.6)	62(48.1)
item10	41(89.1)	34(82.9)	34(80.9)	109(84.5)
Total	336(73.0)	276(67.3)	276(68.1)	898(69.6)

a. N: correct number; %: proportion of correct number

b. Detail items of the Reproductive Knowledge Scale (the significant items were in bold):

Item1. During pregnancy preparation, the positive party needs to undergo antiviral therapy and the viral load test reaches sustained inhibition (< LDL (Lower Detection Limit) or less than 50 copies per milliliter), you can adopt condom-free sex. Item2. When preparing for pregnancy, the negative party needs to take prophylactic medication before and after exposure under the guidance. Item3. If the negative party has a negative antibody test before and after exposure to prophylaxis, the child does not need to be tested again after birth. Item4. Negative and positive parties need to be screened for venereal diseases and reproduction before pregnancy. Item5. Women need to take folic acid for three months to prepare for pregnancy. Item 6, without the intervention of antiviral treatment to prepare for pregnancy, it is possible to let each other be infected. Item7. Antiviral therapy can greatly reduce the risk of HIV transmission between spouses in singly positive families. Item8. If the women is HIV positive and the pregnancy is successful, the child born to her should take preventive drugs within 6 h after birth, which can reduce mother-to-child transmission. Item9. If the male is HIV positive, pregnancy preparation can be carried out after antiviral treatment is carried out. Item10. Untreated or unsuccessful serodiscordant families may cause infection of newborns and spouses.

Discussion

This study provided important information regarding fertility desire and associated risk factors among HIV-positive MSM. There were few studies on the fertility intention of HIV-positive MSM. Although the percentage of fertility intentions in HIV-positive people or serodiscordant couples was different with HIV-positive MSM, these studies were by and large consistent. In our study, a third HIV-positive MSM reported fertility intentions. A previous study was conducted in Ethiopia, which showed among PLHIV, 58.8% have future fertility desire, and a survey conducted in the same region in the east from 456 sampled PLHIV 192 (42.1%) have fertility desire (Dina et al., 2021; Sufa et al., 2014). The study investigated fertility desire using the question “Would you like to have children in the future?” and the variable was dichotomized into “had no desire”, and “had fertility desire”. Another study in Kenya found that 34% of the study participants have future fertility desires (Wekesa & Coast, 2014), and the study assessed fertility desire using the question “Would you like to have another child or would you prefer not to have any (more) children?”. In a study among 487 PLHIV in Kunming, China, fifty percent were females. Overall, 38.4% of the respondents answered that they were likely to have another child in the next three years (Guo et al., 2022). This study measured fertility desire by the question: “Do you want to have another child at the present?” The possible responses were “yes”, “not sure”, or “no”.

Drivers of fertility desire were complicated, and our study found some significant factors associated with the desire. Most of the respondents in our study were single MSM, and the proportion of those who did not want to have children was lower than that of those who did. While of the 15 percent who are married, most had no intention of having children. A cross-sectional study conducted among HIV-positive individuals in public health hospitals of Addis Ababa City in 2021 showed that being married (aOR = 2.89, 95% CI: 1.39, 5.99) was associated with future fertility desire (Tilahun Wassie et al., 2022). The results were inconsistent with our findings. The possible reason might be that 99.8% of the 499 participants in the study were infected by mother-to-child transmission, which was different from the type of participants in our study. One study analyzed the marital status of HIV-positive MSM in China in 2014. The results showed that among the 22,337 participants, those who under 30 years old were had a lower proportion of being married, and those who were over 45 years old might choose marriage of convenience. Family pressure prompted them to hide their sexual orientation, get married, and have children (Li et al., 2017). Most HIV-positive MSM in our study were young and single. It implied that we should pay more attention to the fertility intention of the HIV-positive MSM population, solving their reproduction problems, and improving the assisted reproductive technologies, which helped reduce the HIV transmission caused by marital sex.

MSM without siblings had a higher percentage of fertility desire. We found that those with less than a high school degree and those with a bachelor's degree had similar rates of intention to have children. The sample size of a master's degree or above in this study was limited, and the results showed that there was a higher proportion of fertility intention among HIV-positive MSM with a master's degree or above. It was related to the fact that MSM with higher education levels might have higher social status and more advanced thinking, so they were more aware of or believed that it was possible to prevent HIV transmission to the next generation. The fertility desires were similar across average income groups in our study. One study showed that a serodiscordant couple’s SES was significantly associated with the desire for more children; fertility desires were lower among low SES compared with high SES couples (Brahmbhatt et al., 2019). Taking into account the cost of childbirth and ensuring the living standards of the next generation, people with high socioeconomic status (SES) will have a higher desire to have children.

Surrogacy was the most desired method to have a child among the 86 respondents who had the desire or did not think clearly. And nearly half of the respondents with a desire to have children chose surrogacy as the ideal way to give birth, most of them were single. Gestational surrogacy was a practice whereby a woman (the “surrogate”) bears a pregnancy for the intended parent(s) to hand over the resulting child, which could provide a way to build a family and conceive the next generation among single men and same-sex male couples (Carone et al., 2018). In this study, most respondents chose surrogacy as the desired way of giving birth, and the possible reason was that in their cognition or information they obtained, surrogacy was an alternative and preferable way of giving birth to a single person. And it avoided heterosexual sex behaviors. At the same time, surrogacy can reduce custody disputes to some extent. But in many countries, including China, surrogacy is banned by law, and children who were born through surrogacy might need appropriate ways to accept and understand their origins, which may affect their mental health to some extent. At the same time, hospitals that could offer assisted reproductive technology in China were unable to provide services to HIV-positive people, which might also affect their choice of desired reproductive methods.

The reproduction-related knowledge scale of HIV-positive MSM used in this study had good reliability. It was essential that individuals were aware of HIV risk factors and that effective transmission prevention strategies were employed. The results suggested that when treated with antiviral therapy, the participants did not know what level of viral loads they needed to have to prepare for pregnancy, nor did they know what women should do to prepare for pregnancy or to get pregnant. Notably, we found that most of those who were married and had fertility desires chose natural conception as their preferred method of reproduction. It implied that efforts were needed to educate HIV-positive MSM about HIV and perinatal HIV transmission. Our results were consistent with some other studies showing poor reproductive knowledge in HIV-positive MSM. One qualitative study in an urban academic center in the United States showed that fifty-one pregnant individuals and their partners had inaccurate knowledge about perinatal HIV transmission (Leziak et al., 2021).

The study had some limitations. Our sample size was not large enough to get representative and universal study results, but still provided some data support for understanding the fertility intention and related knowledge among HIV-positive MSM. On the other hand, we did not divide the roles of MSM and did not analyze the comparison of the fertile intention of MSM of different roles in sexual behaviors. For future work, it was necessary to expand the sample to further understand the fertility intention of HIV-positive MSM with different demographic characteristics and roles in sexual behaviors.

In summary, marital status, and number of siblings, affected the fertility desire among HIV-positive MSM. Moreover, surrogacy became the expected mode of childbearing by most MSM who had the intention to have children, which suggested that we should promote the improvement of current assisted reproductive technology and services. At the same time, improving the understanding of HIV knowledge and attitudes among MSM was also critical to addressing HIV prevention through public health interventions.

Ethical considerations

The study has been approved by the Ethics Committee and Internal Review Boards of Beijing Ditan Hospital, Capital Medical University. And followed the guidelines formulated by Beijing Ditan Hospital, Capital Medical University Ethics Committee. (NO. DTEC-KY2021-022-02).

Acknowledgements

We are grateful to J Han, HX Zhao for their helpful comments on an earlier draft of this paper. We thank the patients who participated in the research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Beijing Municipal Administration of Hospitals’ Ascent Plan (DFL20191802); Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (ZYLX202126); High-level public health technical personnel construction project (2022-3-036).