HIV infection and sexual behaviour in primary and secondary infertile relationships: a caseecontrol study in Kigali, Rwanda

Objective To compare the prevalence of sexually transmitted infections (STIs) (including HIV) and of highrisk sexual behaviour in the following three groups: primary infertile relationships, secondary infertile relationships and fertile relationships. Primary infertility is here defined as never having conceived before, secondary infertility as infertility subsequent to having conceived at least once. Design Unmatched caseecontrol study. Methods Sexually active infertile women aged 21e45 years presenting at an infertility clinic of the Kigali Teaching Hospital, Rwanda and their male partners were invited to participate. Fertile controls who had recently delivered were recruited from the community. In a face-to-face interview, participants were asked about sociodemographic characteristics and their sexual behaviours, and tested for HIV and STIs. Results Between November 2007 and May 2009, 312 women and 254 partners in infertile relationships and 312 women and 189 partners in fertile relationships were enrolled. Involvement in a secondary infertile relationship was associated with HIV infection after adjusting for sociodemographic covariates for women (adjusted OR (AOR)1⁄44.03, 95% CI 2.4 to 6.7) and for men (AOR1⁄43.3, 95% CI 1.8 to 6.4). Involvement in a primary infertile relationship, however, was not. Secondary infertile women were more likely to have engaged in risky sexual behaviour during their lifetime compared with primary infertile and fertile women. Men in primary and secondary infertile relationships more often reported multiple partners in the past year (AOR1⁄45.4, 95% CI 2.2 to 12.7; AOR1⁄47.1, 95% CI 3.2 to 15.8, respectively). Conclusions Increased HIV prevalence and risky sexual behaviour among infertile couples is driven by secondary infertility. Infertile couples, and especially those with secondary infertility, should be targeted for HIV prevention programmes and their fertility problems should be addressed. INTRODUCTION Infertility and HIV infection are affecting a large number of couples world wide with sub-Saharan Africa bearing the largest burden of these two reproductive disorders. It is estimated that in this region 2.5% of adults are living with HIV. Primary infertility (never having conceived) is affecting 3e6% of couples, whereas the prevalence of secondary infertility (infertility after having conceived at least once before) is much higher, especially in certain regions, affecting 5e25% of couples. A number of studies have shown an association between infertility and HIV infection, focusing mainly on reduced fecundity among HIV-positive women compared with HIV-negative women. HIV-positive women (also those with asymptomatic infection) have lower conception rates and higher rates of pregnancy loss. The lower conception rate is thought to be due to greater susceptibility to pelvic inflammatory disease with resultant tubal factor infertility and to weight loss related anovulation, amenorrhoea, male hypogonadism and impaired spermatogenesis. However, in one prospective study examining the association between HIV infection and infertility, it was found that in half of the patients the infertility had existed before HIV infection, suggesting that infertility is a risk factor for HIV acquisition. Previous studies in sub-Saharan Africa have shown that couples with fertility problems are likely to face extramarital relationships, polygamous unions and divorce, all of which are known risk factors for HIV infection. Few studies have examined the HIV prevalence and current sexual behaviours in infertile patients, particularly among couples. In Tanzania, HIV infection was threefold higher among infertile women than among fertile controls, and perceived partner infidelity was higher among infertile women. Similarly, in Nigeria, HIV infection among women undergoing laparoscopy evaluation for infertility was fivefold higher than HIV prevalence among pregnant women. Most HIV transmission in sub-Saharan Africa is thought to be through heterosexual transmission among HIV discordant couples in stable relationships. 18 Couples in infertile relationships may constitute an important vulnerable group for HIV infection in African society and may fuel the HIV epidemic. Little is known about the association between infertility, risky sexual behaviour and sexually transmitted infections (STIs), including HIV. We therefore examined whether HIV/STI infection and risky sexual behaviour were more common among men and women in primary and secondary infertile relationships than among men and women in fertile relationships in an urban population in Kigali, Rwanda. MATERIAL AND METHODS Study population and setting Between November 2007 and May 2009, an infertility research clinic was opened at the Kigali Teaching Hospital in Rwanda (the largest public hospital in Rwanda), and infertile women were International Centre for Reproductive Health, Ghent University, Ghent, Belgium Projet Ubuzima, Kigali, Rwanda Microbiology Department, Ghent University, Ghent, Belgium National University of Rwanda, Microbiology Department, Butare, Rwanda Belgian Technical Cooperation, Rwanda Management Sciences for Health, Rwanda Academic Medical Centre of the University of Amsterdam, Department of Internal Medicine, The Netherlands Institute for Global Health and Development, Amsterdam, The Netherlands Correspondence to Dr N Dhont, c/o Projet Ubuzima, Rue Akagera n 715, Kiyovu, Kigali, Rwanda; [email protected] Accepted 3 August 2010 Published Online First 18 September 2010 28 Sex Transm Infect 2011;87:28e34. doi:10.1136/sti.2010.042879 Epidemiology group.bmj.com on November 14, 2012 Published by sti.bmj.com Downloaded from