Fabienne Marcellin

Camelia Protopopescu

Claude Abé

Sylvie Boyer

Jérôme Blanche

Pierre Ongolo-Zogo

Sinata Koulla-Shiro

Jean-Paul Moatti

Patrizia Carrieri

Bruno Spire

Desire for a child among HIV-infected women receiving antiretroviral therapy in Cameroon: results from the national survey EVAL (ANRS 12-116)

Keywords: antiretroviral therapy, desire for a child, Africa

ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Please find below the answers to the reviewers' questions and suggestions. We have also enclosed a Microsoft Word version of the revised manuscript.

We hope that this revised version will meet the criteria for publication in your journal, and we remain at your disposal to make any changes which could further improve our manuscript.

With best regards,

COMMENTS TO THE AUTHOR

Review -Desire for a child among HIV-Infected women receiving antiretroviral therapy in Cameroon: results from the national survey EVAL 1-In the abstract and in the conclusion, the authors tell us that "... As a conclusion, the desire to have a child is frequent among ART-treated WLHA in Cameroon. Data suggest that the recovery of health thanks to ART has opened up new life perspectives for these women"... I think they couldn´t confirm this, if they are using the desire to have a child as an indicator of new life perspectives, because they investigated only ART-treated women, and we know, and themselves said in the discussion, that the desire to have a child persist in WLHA, despite HIV infection.

I think it would be very interesting if they had analysed both groups of HIV women, with and without ART-treatment, and compare them. But, it must be too late for this now, so I suggest to the authors to be very careful in their conclusions.

The reviewer is right to underline that our results do not demonstrate any causal relationship between "receiving ART" and "reporting the desire to have a child". However, we found that, among ART-treated women, those who had a CD4 level below 200 cells/mm 3 at the time of treatment initiation had significantly higher odds of reporting desire for a child than those with higher CD4 level at treatment initiation. Our hypothesis was that women with the most advanced immunodeficiency at treatment initiation may have delayed their pregnancy for health reasons; then, once recovered thanks to ART, may have regained enough confidence in the future to be able to think about positive personal projects, such as pregnancy. This result is partly confirmed by the fact that CD4 level at the time of the survey was not significantly associated with the outcome (result not shown), which suggests that it is the history of severe immunosuppression followed by a substantial recovery rather than the only immunological response to treatment that can give "hope".

However, we agree that this hypothesis may be somewhat hazardous, considering that we only had cross-sectional data, and no information about desire for a child at treatment initiation for instance (this is one of the limitations of our study, that we have described in the "Discussion" section). As a consequence, we have chosen to remove the following sentence from the "Conclusion" sections of the abstract and manuscript: "Data suggest that the recovery of health thanks to ART has opened up new life perspectives for these women".

In order to better explain our hypothesis, we have also modified the following sentence in the "Discussion" section of the manuscript:

Original version: "On the other hand, the dramatic change in life prognosis thanks to ART has enabled WLHA to take the reins in their lives, especially for those women whose disease is already at a very advanced stage when they initiate therapy."

Revised version:

"On the other hand, women with the most advanced immunodeficiency at treatment initiation may have delayed their pregnancy for health reasons; then, once recovered thanks to ART, may have regained enough confidence in the future to be able to think about positive personal projects, such as pregnancy. This result was partly confirmed by the fact that CD4 level at the time of the survey was not significantly associated with the outcome (result not shown), which suggests that it is a history of severe immunosuppression followed by a substantial recovery rather than the only immunological response to treatment that is likely to revivify WLHA's desire for a child."

2-

They defined desire for a child in 4 categories, the third is "I am pregnant", and they considered this as a desire to have a child. I don't agree. To be pregnant not always means desire to have a child. I think it´s better to separate them for analyses.

We agree with the reviewer concerning the fact that some pregnancies may be unwanted. For this reason, in a primary analysis, we grouped pregnant women with women who reported the desire for a child; then, in a sensitivity analysis, we excluded pregnant women from the analysis. However, we now recognize that the latter approach may be the best in our particular case. Indeed, unfortunately, we have no information about the desire for a child among women who were pregnant at the time of the study, so that we cannot classify them easily into "wanted" or "unwanted" pregnancies (in the survey questionnaire, women were asked if they had the desire to have a/another child, with the possible following answers: (1) yes, I wish I will have a/another child (2) no, I do not want a/another child (3) I am pregnant (4) I cannot have a/another child (infertility, menopause ... etc)).

We have thus decided to exclude pregnant women from our analysis. The text and tables have been modified accordingly (please see revised manuscript for these major changes).

3-

They have many results that would be more explored in discussion and even in the conclusion as the other factors significantly associated with desire for a child, and compare them with the literature about desire for a child in women without HIV infection, in order to verify if there are differences between these two populations.

As suggested by the reviewer, we have further explored the impact of economic conditions on women's desire for a child, by comparing our results to the findings of studies among non-HIV-positive women in Asia and Eastern Europe. To that end, we have added the following sentence to the "Discussion" section: [START_REF] Mahmood | The desire for additional children among Pakistani women: the determinants[END_REF][START_REF] Ranjan | Fertility behaviour under income uncertainty[END_REF]

"Economic factors such as the level of income of the household have also been shown to play a key role in the fertility intentions of women who are not HIV-infected, notably in Eastern Europe and Asia

4-

They should give more attention to data about knowledge and beliefs about HIV and ART, and make some suggestions to the services in order to improve information given to their customers.

We agree with the reviewer concerning the importance of taking into account individuals' knowledge and beliefs about HIV, especially in the African context, in order to better tailor the social response to the AIDS epidemic. As suggested, we have modified the discussion of women's knowledge and beliefs about HIV and we have made some suggestions about the way to improve prevention and counselling. These changes are as follows ("Discussion" section):

Original version: "Results also showed that better knowledge about HIV and its transmission modes was associated with more frequent report of the desire to have a child, which suggests that women who received information about the disease were better armed to face it. At this point, it must be noted that nearly all women in the present study had integrated fundamental information about HIV (viral cause, main transmission modes, ability of ART to stabilise the development of the disease, risk of mother-to-child transmission), which constitutes an encouraging outcome for the information campaigns conducted in Cameroon."

Revised version:

"Results also showed that better knowledge about HIV and its transmission modes was associated with more frequent report of the desire to have a child, which suggests that women who received information about the disease were better armed to face it. At this point, it must be noted that nearly all women in the present study had integrated fundamental information about HIV. We have also modified the "Conclusion" section of the manuscript as follows:

Indeed, more than nine women in ten knew about the viral origin of the disease, its main transmission modes (through blood and sexual fluids), the ability of ART to stabilise the development of the disease, and finally, the risk of mother-to-child HIV transmission. Although this constitutes a very encouraging outcome for the information campaigns conducted in Cameroon, there is still much work to do, as some erroneous beliefs go on coexisting with correct basic knowledge and turn out to be detrimental for women's life plans. These are mainly either deeply ingrained popular beliefs (such as belief in the influence of spirits or supernatural forces) or widespread rumour, closely related to both the fear of getting infected and the stigmatization of infected individuals (such as believing that HIV can be transmitted through saliva). In addition, some women still perceive ARV as a curative therapy. These findings highlight the need for developing information and counselling actions on HIV and ART on a regular basis during the follow-up of WLHA, while most information actions are currently conducted at the time of HIV diagnosis and at initiation of ART. These actions should be tailored to the African socio-cultural context. The power of rumour and gossip must be taken into account and used to counteract the distrust and resistance to more formal channels of communication: for instance, community radio broadcasts can be effectively used to spark rumours about HIV containing positive prevention messages (Stadler 2003). In addition, prevention from peers should be maintained and reinforced in HIV care centers, as well as the involvement of HIV-infected people associations in the follow

Original version: "The desire to have a child is frequent among ART-treated WLHA of reproductive age in Cameroon. Results suggest that recovery of health thanks to ART has opened up new life perspectives for these women. In a national context of the scaling-up of ART, these data suggest that HIV care and family planning programs should be better integrated in order to support WLHA's reproductive choices. Counselling actions should be developed to support WLHA who desire children to maximise their chances to live a healthy pregnancy and to give birth to a HIV-negative baby."

Revised version:

"The desire to have a child is frequent among ART-treated WLHA of reproductive age in Cameroon. Apart from women's reproductive potential (younger age, living in a couple, already being a mother, having frequent sexual relationships), the correlates of this desire comprise, on the one hand, the experience of the HIV disease, through past immunodeficiency and perception of physical HRQL at the time of the survey; and, on the other hand, a good knowledge of HIV and ART. In a national context of the scaling-up of ART, these data suggest that HIV care and family planning programs should be better integrated in order to support WLHA's reproductive choices. Counselling and information actions should be developed on a regular basis throughout women's follow-up. Future prevention strategies should consider alternative channels of communication and should further encourage the involvement of peers in order to support WLHA who desire children, and to maximise their chances to live a healthy pregnancy and to give birth to a HIV-negative baby."

REFEREE: 2 COMMENTS TO THE AUTHOR

1. The paper was interesting to read. There are a few suggestions.

2. Chapter -Introduction -may be apart from Africa as a whole, you may want to set out the situation in Cameroon including the socio-economic and demographic situation. Some of the literature review that you have in the Discussion section could also move here as then it sets the rationale of your study.

As suggested by the reviewer, we have added information about the socio-economic and demographic situation in Cameroon in the "Introduction" section, as follows: In addition, we have moved some sentences from the "Discussion" section to the "Introduction" section of the manuscript, and we have done some modifications in the "Introduction" section, as follows:

"With a HIV prevalence rate of 5.1% in a total population of more than 18 millions of individuals, Cameroon is among those western and central African countries most affected by the AIDS epidemic (UNAIDS 2008). The management of HIV infection is a great challenge for this country, in which 40% of individuals live under the poverty line (defined as 20,000 FCFA per equivalent adult and per month) (United Nations Statistics Division 2008) and which is characterized by a very young population (with 48% of individuals being less than 49 years old) and a high fertility rate (4.5 children per woman) (WHO-UNAIDS 2008)."

Original version: "Sub-Saharan Africa remains the region most affected by the global AIDS epidemic, with the majority of HIV-infected individuals being women (UNAIDS and WHO 2007). Many of these women are of reproductive age and despite their infection their desire to bear a child remains strong, especially in a social context which considers motherhood as a cornerstone of a woman's identity [START_REF] Desgrées Du Loû | Sexualité et procréation confrontées au sida dans les pays du Sud[END_REF]. Sexual and reproductive health of women living with HIV/AIDS (WLHA) in Africa is given a growing attention [...] [START_REF] Bungener | African and European HIV-positive women: psychological and psychosocial differences[END_REF][START_REF] Heard | Reproductive choice in men and women living with HIV: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA Study)[END_REF]).

Sexual and reproductive health of women living with HIV/AIDS (WLHA) in Africa is given a growing attention."

3. Chapter -Methods -Was your sample from married or unmarried group? Or both? What was the age group -you say 21 years or older in Patients section and then say fertile women of reproductive age in the Results section. May be if you specify the age range of the participants, this may be clear.

The population analyzed comprised both married and unmarried women. Indeed, among the 1433 women included in the analyses, only 26.3% were married. This figure appears in Table 1. In the revised manuscript, we have added this information in the "Results" section as follows:

Original version: "About four women in ten reported they were living in a couple, and half of those included had at least two biological children."

Revised version:

"About four women in ten reported they were living in a couple, 26% were married, and half of those included had at least two biological children."

Concerning the age group, eligibility criteria for participating in the EVAL survey included being aged 21 years or older. However, our analyses focused only on ART-treated women of reproductive age (<50 years old) who did not report the inability to have children (and were thus considered as fertile). For a purpose of clarity, we have modified the last sentence of the "Patients" section as follows:

Original version: "Our analyses were restricted to those women who participated in EVAL and were receiving ART at the time of the survey."

Revised version: "Our analyses were restricted to fertile women of reproductive age (<50 years old) who participated in EVAL and were receiving ART at the time of the survey."

In addition, we have added the age range of the participants in the "Results" section as follows:

Original version: "Median age [interquartile range 25%; 75%, IQR] was 33 [29; 39] years in this population (Table 1)."

Revised version:

"Median age [interquartile range 25%; 75%, IQR] was 33 [29; 39] years in this population (Table 1), with a minimum of 21 years old and a maximum of 49 years old."

4. It would be interesting to know a bit more about the EVAL survey -may be as a footnote?

The EVAL survey is a research project funded by the French National Agency for Research on AIDS and viral hepatitis (ANRS) which aims at evaluating the national program for improving access to antiretroviral therapy (ART) in Cameroon. As suggested by the reviewer, we have added the following sentences as a footnote in the "Methods" section:

"The EVAL survey is a research project which aims at evaluating the Cameroonian national program for improving access to ART. It was funded by the French National Agency for Research on AIDS and viral hepatitis (ANRS) and approved by the Ministry of Public Health in Cameroon and the Cameroonian National Ethics Committee."

5. Chapter -Definition of the desire for a child -It is interesting to note that you removed women who could not have a child and you clubbed those who wished to have a child with those who were pregnant. In some papers that I have read, it appears that the pregnancy could be unwanted too. Is it possible to analyse the data with these groups as independent? May be club all those who were currently pregnant and wanted a child with the group which wants a child. It would be interesting to note if there are any differences among these groups. Also, it would be good to know how many women fell in each category. However, it would be interesting to separate out further among the pregnant group how many wanted and how many did not want a child. You performed a Sensitivity test to rule out the unwantedness of the pregnancy and excluded those women from the outcome. I would like to learn more about this test? How does it work? And is really fair to exclude these women from the final analysisdoes it not give us an understanding of the desire or lack thereof for a child? We totally agree with the reviewer concerning the fact that some of the women who were pregnant at the time of the survey may not have deliberately chosen to have a baby. As a consequence, clubbing these pregnant women with those women who did report that they wanted a/another child may result in an overestimation of the number of women who actually desired a child. For that reason, we performed a sensitivity analysis excluding pregnant women from the population analyzed. Sensitivity analyses are not statistical tests per se but consist in redefining the population analyzed (usually by removing, adding or modifying the classification of a few individuals causing problem) then re-running the final statistical model on this new dataset in order to verify the stability of associations between variables. This is a convenient method to use when a small fraction of the population cannot be easily classified in either category of the outcome of interest. That is the case in our study, in which the 23 pregnant women cannot be easily classified in "desire a child" or "do not desire a child". Unfortunately, we cannot have information about the number of pregnant women who fall in each of these two categories, as the question about the desire for a child in the survey questionnaire had only 4 possible answers, as follows: (1) yes, I wish I will have a/another child (2) no, I do not want a/another child (3) I am pregnant (4) I cannot have a/another child (infertility, menopause ... etc). For a purpose of clarity, we have finally decided to exclude pregnant women from the analyses (please see revised manuscript for these in-depth changes in the text and tables). We have also modified the following sentences in the paragraph describing the study limitations ("Discussion" section):

Original version: "Finally, it must be noted that the categories in the outcome variable are not mutually exclusive. Indeed, for instance, a woman who is infertile could wish to have a child, while a woman who is pregnant might not desire to have one. However, for a purpose of homogeneity of the study population, the aim of our analysis was to explore the determinants of the desire for a child among ART-treated fertile women. In this context, the use of a close question to assess women's desire for a child, without allowing multiple answers, was a deliberate choice."

Revised version:

"In addition, it must be noted that the categories in the outcome variable are not mutually exclusive. In particular, a woman who is infertile could wish to have a child. However, for a purpose of homogeneity of the study population, the aim of our analysis was to explore the determinants of the desire for a child exclusively among fertile women. In this context, the use of a close question to assess women's desire for a child, without allowing multiple answers, was a deliberate choice. Finally, the present study is also limited by the lack of information concerning desire for a child among pregnant women (n=23), who were thus excluded from the analyses".

6. Chapter -Results -Through the paper, would it be possible to round off the percentage for example, 19.4% could be 19% and 90.7% could be 91%. We do see the decimal points in the table -but in the text may be keep it to a rounded off figure?

As suggested by the reviewer, we have rounded all the percentages which appeared in the text. 7. Chapter -Results (contd.) -The section on socio-economic status-there are some points in the text which are not in the table -for this may be you can say in bracket -not shown in table 1? For example -...nine in ten reported being the only person to contribute to the household income; and another place you say 37% of women had experienced AIDS defining eventswhat are these events? You also mention women reporting a median of 6 symptoms during the previous four weeks -what are these symptoms? Even in the table you indicate self reported symptoms, general symptoms and lipodystrophy symptoms -for a non-medical person, just a listing would give an indication of what you mean.

As suggested, we have added the mention "not shown in the table" where needed in the "Results" section, as follows: "Among sexually active women who reported using contraception, the methods most often chosen were condoms (91% of women) and sexual abstinence or the withdrawal method (15% of women) (not shown in the table) [..

.] Forty-one percent reported being the head of their household, and among these nine in ten reported being the only person to contribute to the household income (not shown in the table)."

We used the terms of "AIDS-defining events" to identify the list of conditions used to define the end stage of the HIV disease (CDC stage C), including for instance Kaposi's sarcoma, recurrent pneumonia, and wasting syndrome due to HIV. In our study, we only had access to information about the patients' clinical stage (CDC C versus A or B), without detailed information about the type of AIDS-defining events that patients had experienced. For a purpose of clarity, we have modified the corresponding sentence as follows:

Original version: "Thirty-seven percent of women had experienced AIDS-defining events."

Revised version: "Thirty-seven percent of women had experienced AIDS-defining events (CDC stage C)."

The list of self-reported symptoms is as follows:

-general symptoms (derived from the HIV symptom index by Justice et al, J Clin Epidemiol 2001): nausea, vomiting, burning in the stomach, stomach pain, change in the taste of food, bladder or kidney stones, diarrhoea, headache, fatigue, fever, difficulty falling or staying asleep, tickling around the mouth, aching muscles, aching feet and legs (neuropathy), itching skin, hallucinations or dizziness, problems having sexual intercourse and hair or fingernails problems.

-lipodystrophy-related symptoms: change in overall body shape, hollow cheeks, larger belly or wider waist, slimmer arms, slimmer buttocks, slimmer legs, veins on the legs becoming visible, larger breasts, accumulation of fat in the neck.

As suggested by the reviewer, we have given additional indications in the text as follows:

-in the "Variables" section:

Original version: "Self-reported symptoms were collected using a 27-item list, which was based on the selfcompleted HIV symptom index developed by Justice et al. [START_REF] Justice | Development and validation of a self-completed HIV symptom index[END_REF], and included 18 general symptoms often observed during ART (such as headache, fatigue or diarrhea) [START_REF] Carrieri | Factors associated with nonadherence to highly active antiretroviral therapy: a 5-year follow-up analysis with correction for the bias induced by missing data in the treatment maintenance phase[END_REF] and nine other symptoms related to lipodystrophy [START_REF] Duran | Failure to maintain long-term adherence to highly active antiretroviral therapy: the role of lipodystrophy[END_REF]."

Revised version: "Self-reported symptoms were collected using a 27-item list, which was based on the selfcompleted HIV symptom index developed by Justice et al. [START_REF] Justice | Development and validation of a self-completed HIV symptom index[END_REF], and included 18 general symptoms often observed during ART (nausea, vomiting, burning in the stomach, stomach pain, change in the taste of food, bladder or kidney stones, diarrhoea, headache, fatigue, fever, difficulty falling or staying asleep, tickling around the mouth, aching muscles, aching feet and legs (neuropathy), itching skin, hallucinations or dizziness, problems having sexual intercourse and hair or fingernails problems) [START_REF] Carrieri | Factors associated with nonadherence to highly active antiretroviral therapy: a 5-year follow-up analysis with correction for the bias induced by missing data in the treatment maintenance phase[END_REF] and nine other symptoms related to lipodystrophy (change in overall body shape, hollow cheeks, larger belly or wider waist, slimmer arms, slimmer buttocks, slimmer legs, veins on the legs becoming visible, larger breasts, accumulation of fat in the neck) [START_REF] Duran | Failure to maintain long-term adherence to highly active antiretroviral therapy: the role of lipodystrophy[END_REF]." -in the "Results" section:

Original version: "Finally, women reported having a median of 6 [3; 9] symptoms during the previous four weeks, and more than nine in ten had physical and mental HRQL score values above 25, on a scale from 0 to 100."

Revised version: "Finally, women reported having a median of 6 [3; 9] symptoms during the previous four weeks. Fatigue and headache were the general symptoms most often reported (with 59% and 52% of women concerned, respectively), while change in overall body shape and larger belly or wider waist were the lipodystrophy-related symptoms most often reported (with 40% and 22% of women concerned, respectively) (not shown in the table).

In addition, more than nine in ten had physical and mental HRQL score values above 25, on a scale from 0 to 100."

We have also given the detailed list of symptoms as a footnote in Table 1.

8. The data are very interesting and fascinating. But there may be a chance for more in-depth analysis. In the multivariate analysis -may be make an index of socio-economic status, Knowledge and belief about HIV, Modes of transmission and mechanism of action rather than show each variable under each of these titles. I note that in the Discussion chapter, you mention that all women had integrated fundamental information about HIV but in the multivariate analysis you have looked at a few -any particular reason? Creating indices would make the analysis crisper.

We prefer not to sum up the information about women's socio-economic status using a single index, as we think that each variable in this category is interesting to consider in its own. However, we totally agree with the reviewer concerning the advantages of defining indices for the category "Knowledge and beliefs about HIV and ART", including the subcategories "Origin of the disease" (3 questions), "Modes of transmission" (6 questions) and "Mechanisms of action of antiretrovirals" (5 questions). We have calculated three aggregate scores, by scoring women's answers to each question (1 for a correct answer; 0 for an incorrect or a "do not know" answer), then summing these scores for each subcategory. Consequently, we have obtained a score ranging from 0 to 3 for "Origin of the disease", a score ranging from 0 to 6 for "Modes of transmission", and a score ranging from 0 to 5 for "Mechanisms of action of antiretrovirals", with a higher score denoting better knowledge.

We have added the following sentences in the "Statistical analysis" section of the manuscript: "Three aggregate scores were calculated to sum up the information concerning women's knowledge and beliefs about the origin of the HIV disease (score ranging from 0 to 3), the modes of transmission of HIV (score ranging from 0 to 6), and finally the mechanisms of action of antiretrovirals (ARVs) (score ranging from 0 to 5). To this end, correct answers were rated 1, while incorrect or "do not know" answers were rated 0. These rates were then added to obtain the aggregate scores. Higher scores denote better knowledge."

A description of the distributions of these three scores has been added to These data have been added to Table 3 (please see revised manuscript).

In the multivariate analysis, the score for "Origin of the disease" was found to be independently associated with women's report of desire for a child (p=0.008). Adjusted odds ratios presented in Table 3 have been modified accordingly (please see revised manuscript).

The following sentence has been added to the "Statistical analysis" section: "In addition, aggregate scores were entered in the multivariate model, preferably to separate variables for knowledge and beliefs about HIV and ART."

In addition, the following sentence has been added to the "Results" section: "In addition, a good knowledge about the origin of the HIV disease was also found to be independently associated with women's desire for a child."

Concerning the second point suggested by the reviewer, fundamental information about HIV refers to basic knowledge about the disease, comprising knowledge of the viral origin of the disease, of the main transmission modes (unprotected sexual relationships, blood transfusion, mother-to-child transmission) as well as knowledge of the main mechanism of action of antiretrovirals (ie to stabilize the disease).

Our results show that this fundamental information has been well integrated by women, as more than nine women in ten in the study gave the right answers to the corresponding questions, as described in the "Results" section of the manuscript. For that reason, in the original version of the manuscript, we had chosen not to test these variables in the logistic regression models, as explained in the "Statistical analysis" section:

"Each factor was first tested for its association with the desire for a child in a univariate model, excluding categorical variables with classes concerning less than 5% of individuals."

In the revised version of the manuscript, these variables have been used to calculate the aggregate knowledge scores.

9. Chapter Discussion -This chapter has literature review and this could be moved to the beginning of the paper -as a synopsis. In this chapter, I wonder why have you referred to others who have found similar outcomes -may be just a line saying -our findings confirm or reiterate the outcomes suggested by other researchers and then put everyone's names thereand this could be at the end -this would save you words.

Following the reviewer's suggestion, we have tried to simplify the discussion to make it less wordy, and we have added an in-depth discussion of the impact of women's knowledge and beliefs on their desire for a child (please see revised manuscript for these major changes).

10. And finally, the Conclusion chapter seems very weak -you have very interesting findings that have major policy implications -please use those.

Following these suggestions, we have modified the "Conclusion" section as follows:

Original version: [START_REF] Bungener | African and European HIV-positive women: psychological and psychosocial differences[END_REF][START_REF] Heard | Reproductive choice in men and women living with HIV: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA Study)[END_REF]).

Sexual and reproductive health of WLHA in Africa is given a growing attention1 .

However, while many African countries have initiated national programs to improve access to antiretroviral therapy (ART) and HIV care, the determinants of the reproductive intentions of WLHA who obtain access to ART in a scale-up context are still poorly documented [START_REF] Myer | Prevalence and determinants of fertility intentions of HIV-infected women and men receiving antiretroviral therapy in South Africa[END_REF][START_REF] Kaida | Use of antiretroviral therapy is associated with increased fertility desires but decreased likelihood of pregnancy and livebirth among HIVpositive women in Mbarara, Uganda[END_REF][START_REF] Mokgatle-Nthabu | HIV positive women's perception of mother to child transmission and the desire to bear children: implications for HIV prevention[END_REF].

With a HIV prevalence rate of 5.1% in a total population of more than 18 millions of

Definition of the desire for a child

Face-to-face interviews of women included one question about their desire for a child, with the following possible responses: (1) yes, I wish I will have a/another child (2) no, I do not want a/another child (3) I am pregnant (4) I cannot have a/another child (infertility, menopause ... etc). In this study, women who answered (1) or (3) were considered as reporting the desire to have a child. Women who answered (4) were excluded from the analyses. Assuming that some of these pregnancies may have been unwanted, we excluded pregnant women from the analysis.

Variables

Variables included in the analyses concerned the following domains: concerning the mechanisms of action of antiretroviral drugs. Indeed, we hypothesized that they might have an influence on women's perception of their disease, and in turn on their perception of their life in the future. Self-reported symptoms were collected using a 27-item list, which was based on the self-completed HIV symptom index developed by Justice et al. [START_REF] Justice | Development and validation of a self-completed HIV symptom index[END_REF], and included 18 general symptoms often observed during ART (nausea, vomiting, burning in the stomach, stomach pain, change in the taste of food, bladder or kidney stones, diarrhoea, headache, fatigue, fever, difficulty falling or staying asleep, tickling around the mouth, aching muscles, aching feet and legs (neuropathy), itching skin, hallucinations or dizziness, problems having sexual intercourse and hair or fingernails problems) [START_REF] Carrieri | Factors associated with nonadherence to highly active antiretroviral therapy: a 5-year follow-up analysis with correction for the bias induced by missing data in the treatment maintenance phase[END_REF]) and nine other symptoms related to lipodystrophy (change in overall body shape, hollow cheeks, larger belly or wider waist, slimmer arms, slimmer buttocks, slimmer legs, veins on the legs becoming visible, larger breasts, accumulation of fat in the neck) [START_REF] Duran | Failure to maintain long-term adherence to highly active antiretroviral therapy: the role of lipodystrophy[END_REF]. HRQL was assessed using the Medical Outcome Study 12-item Short-Form Health Survey (SF-12  ) [START_REF] Ware | A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity[END_REF][START_REF] Ware | SF-12v2: How to Score Version 2 of the SF-12 Health Survey[END_REF], which explores both physical and mental components of HRQL and enables the calculation of the following two global scores: the physical component summary (PCS) and the mental component summary (MCS). These two scores range from 0 to 100, a higher score value denoting a better HRQL.

Statistical analysis

Three aggregate scores were calculated to sum up the information concerning women's knowledge and beliefs about the origin of the HIV disease (score ranging from 0 to 3), the modes of transmission of HIV (score ranging from 0 to 6), and finally the mechanisms of action of antiretrovirals (ARVs) (score ranging from 0 to 5). To this end, correct answers were The SPSS version 14.0 (SPSS Inc, Chicago, Illinois, USA) and SAS version 9.1 (SAS Institute Inc., Cary, NC, USA) for Windows software were used for the analyses.

RESULTS

Characteristics of ART-treated fertile women of reproductive age

A total of 2,466 patients included in EVAL were receiving ART at the time of the survey, of whom 1,746 were women. Among these women, 234 reported the inability to have children, 55 were more than 50 years old, 23 were pregnant and one had missing data concerning the desire for a child. Analyses were thus restricted to the remaining 1,433 ART-treated fertile women of reproductive age.

(Table 1 four women in ten reported they were living in a couple, 26% were married, and half of those included had at least two biological children. Only 19% reported both having sexual relationships and not using contraception. Among sexually active women who reported using contraception, the methods most often chosen were condoms (91% of women) and sexual abstinence or the withdrawal method (15% of women) (not shown in the table). The other methods (birth control pill, implant, traditional methods) were rarely reported. Only 24% percent of women reported at least two sexual relationships per month, and 40% had disclosed their seropositivity to their main partner.

Regarding socio-economic status, the vast majority of women in the study (79%) lived in an urban or semi-urban area. Forty-one percent reported being the head of their household, and among these nine in ten reported being the only person to contribute to the household income (not shown in the table ). Half of all the women in the analyses had been diagnosed

HIV-positive at least 22 months previous to the study, and HIV diagnosis had occurred during pregnancy for 11% of women. Thirty-seven percent of women had experienced AIDSdefining events (CDC stage C). Women had been receiving ART for 14.7 [7.0; 25.9] months in median [IQR]. Finally, women reported having a median of 6 [3; 9] symptoms during the previous four weeks. Fatigue and headache were the general symptoms most often reported (with 59% and 52% of women concerned, respectively), while change in overall body shape and larger belly or wider waist were the lipodystrophy-related symptoms most often reported (with 40% and 22% of women concerned, respectively) (not shown in the table). In addition, more than nine in ten had physical and mental HRQL score values above 25, on a scale from 0 to 100.

(Table 2 about here)

Nearly all women were aware of the viral origin of HIV, knew about the main transmission modes (unprotected sexual relationships, blood transfusion) and the ability of 2). In addition, more than eight in ten reported they knew that babies from seropositive women could be infected during pregnancy or delivery, that one could not be infected when drinking from the same glass as a seropositive person, that ARV decrease the risk of becoming ill, and that ARV cannot be stopped even when a treated person feels better. However, only four women in ten knew that ARV cannot cure HIV. Women's positions also varied when asked different questions about poverty and supernatural forces as possible causes of HIV as well as the risk of being infected after a mosquito bite or when kissing a seropositive person. Finally, 11% of women thought that a person who takes ARV cannot transmit the virus.

Factors associated with women's desire for a child

(Table 3 about here)

A total of 791 women (55%) reported the desire for a child.

In the univariate analyses, the following factors were significantly associated with the desire for a child: younger age, being married or in a free union, reporting at least two sexual relationships per month, having disclosed seropositivity to one's main partner, feeling supported by one's family or main partner, and having a low number of biological children (Table 3). Univariate analyses also identified the following socio-economic correlates of the desire for a child: women's educational level (high school or university); area of habitation (urban or semi-urban); social status (not being the head of the household; being professionally inactive); household characteristics (high monthly income with at least two persons contributing; having a low number of children in the household). Concerning clinical characteristics and women's perception of their health status, the following were also significantly associated with desire for a child: more recent HIV diagnosis, more recent ART initiation, low CD4 count at ART initiation (<200 cells/mm3) and good physical HRQL. In desire for a child more often than the others, but this association did not reach statistical significance (p=0.13). Finally, women with incomplete knowledge or erroneous beliefs about HIV and ART (whatever the question considered) reported the desire for a child significantly less often than the others. No significant relationship was detected between the desire for a child and the following factors: CDC stage C (p=0.37), CD4 count at last assessment, hospitalization during the previous six months, number of self-reported symptoms and level of mental HRQL (p>0.25, results not shown).

Multivariate analysis confirmed age, matrimonial status, number of biological children, frequency of sexual relationships, CD4 count at ART initiation and physical HRQL as independent determinants of women's desire for a child. In addition, a good knowledge about the origin of the HIV disease was also found to be independently associated with women's desire for a child.

DISCUSSION

In this study conducted in Cameroon in 2007 among 1,456 ART-treated fertile WLHA of reproductive age, more than half of the women reported they wished to have a/another child in the future. While estimates of the prevalence for the desire to have a child vary greatly from one study conducted in resource-limited settings to another [START_REF] Myer | Prevalence and determinants of fertility intentions of HIV-infected women and men receiving antiretroviral therapy in South Africa[END_REF][START_REF] Tamene | Fertility desire and family-planning demand among HIV-positive women and men undergoing antiretroviral treatment in Addis Ababa, Ethiopia[END_REF][START_REF] Kaida | Use of antiretroviral therapy is associated with increased fertility desires but decreased likelihood of pregnancy and livebirth among HIVpositive women in Mbarara, Uganda[END_REF][START_REF] Mokgatle-Nthabu | HIV positive women's perception of mother to child transmission and the desire to bear children: implications for HIV prevention[END_REF], all conclude that a strong desire to have a child exists among ART-treated WLHA. . .

In the present study, no significant relationship was found between women's desire for a child and any of the factors related to their clinical status at the time of the survey, which echoes evidence already found in developed countries [START_REF] Chen | Fertility desires and intentions of HIV-positive men and women[END_REF] et al. 2007;[START_REF] Nobrega | Desire for a child among women living with HIV/AIDS in northeast Brazil[END_REF]. By contrast, women's perception of their physical HRQL together with low CD4 level at ART initiation both act as independent correlates of women's desire for a child. These very interesting findings suggest , on the one hand, that reproductive intentions are more strongly influenced by one's subjective health status than by one's objective clinical status [START_REF] Chen | Fertility desires and intentions of HIV-positive men and women[END_REF]. On the other hand, women with the most advanced immunodeficiency at treatment initiation may have delayed their pregnancy for health reasons; then, once recovered thanks to ART, may have regained enough confidence in the future to be able to think about positive personal projects, such as pregnancy. This result was partly confirmed by the fact that CD4 level at the time of the survey was not significantly associated with the outcome (result not shown), which suggests that it is a history of severe immunosuppression followed by a substantial recovery rather than the only immunological response to treatment that is likely to revivify WLHA's desire for a child. In poor as in high-resource settings, the shock of HIV diagnosis has disastrous consequences on a woman's life plans. In a recent study in Malawi, Hoffmann et al [START_REF] Hoffman | The year-long effect of HIV-positive test results on pregnancy intentions, contraceptive use, and pregnancy incidence among Malawian women[END_REF]) compared women's report of the desire for children before and after express fertility desires compared with ART-naïve women [START_REF] Kaida | Use of antiretroviral therapy is associated with increased fertility desires but decreased likelihood of pregnancy and livebirth among HIVpositive women in Mbarara, Uganda[END_REF]. Using a scale including 23 statements about ART, concern about HIV infection, and concern about transmission to both sexual partners and unborn children during pregnancy, they also showed that women who reported that they desired (additional) children had significantly higher ART optimism scores than women who did not [START_REF] Kaida | The WHOMEN's scale (Women's HAART Optimism Monitoring and EvaluatioN scale v.1) and the association with increased fertility desires among HIV-positive women in Uganda[END_REF].

The present study also confirms that WLHA who report desire for a child in poorresource settings are younger [START_REF] Oladapo | Fertility desires and intentions of HIV-positive patients at a suburban specialist center[END_REF][START_REF] Peltzer | Family Planning Among HIV Positive and Negative Prevention of Mother to Child Transmission (PMTCT) Clients in a Resource Poor Setting in South Africa[END_REF] and have fewer biological children [START_REF] Mantell | Toward improved reproductive health choices and health care delivery for HIV-infected men and women in developing countries with generalised HIV epidemics[END_REF]) than those who do not. These two factors, related to women's reproductive potential, have already been identified as independent correlates of the desire to have a child in developed countries [START_REF] Chen | Fertility desires and intentions of HIV-positive men and women[END_REF][START_REF] Heard | Reproductive choice in men and women living with HIV: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA Study)[END_REF][START_REF] Nobrega | Desire for a child among women living with HIV/AIDS in northeast Brazil[END_REF][START_REF] Ogilvie | Fertility intentions of women of reproductive age living with HIV in British Columbia, Canada[END_REF][START_REF] Paiva | Desire to have children: gender and reproductive rights of men and women living with HIV: a challenge to health care in Brazil[END_REF]. Not surprisingly in our study, women who were living in a couple and those who reported more frequent sexual relationships were significantly more likely to report the desire to have a child than the others.

Results also showed that better knowledge about HIV was associated with more frequent report of the desire to have a child, which suggests that women who received information about the disease were better armed to face it. At this point, it must be noted that nearly all women in the present study had integrated fundamental information about HIV.

Indeed, more than nine women in ten knew about the viral origin of the disease, its main transmission modes (through blood and sexual fluids), the ability of ART to stabilise the development of the disease, and finally, the risk of mother-to-child HIV transmission.

Although this constitutes a very encouraging outcome for the information campaigns conducted in Cameroon, there is still much work to do, as some erroneous beliefs go on coexisting with correct basic knowledge and turn out to be detrimental for women's life plans.

These are mainly either deeply ingrained popular beliefs (such as belief in the influence of infected and the stigmatization of infected individuals (such as believing that HIV can be transmitted through saliva). In addition, some women still perceive ARV as a curative therapy. These findings highlight the need for developing information and counselling actions on HIV and ART on a regular basis during the follow-up of WLHA, while most information actions are currently conducted at the time of HIV diagnosis and at initiation of ART. These actions should be tailored to the African socio-cultural context. The power of rumour and gossip must be taken into account and used to counteract the distrust and resistance to more formal channels of communication: for instance, community radio broadcasts can be effectively used to spark rumours about HIV containing positive prevention messages [START_REF] Stadler | Rumor, gossip and blame: implications for HIV/AIDS prevention in the South African lowveld[END_REF]. In addition, prevention from peers should be maintained and reinforced in HIV care centers, as well as the involvement of HIV-infected people associations in the follow-up of WLHA, in order to pursue the fight against HIV stigma.

Finally, results confirmed that women's educational and economic status, and area of residence (urban versus rural) affect their intentions to have a child [START_REF] Nebie | Sexual and reproductive life of women informed of their HIV seropositivity: a prospective cohort study in Burkina Faso[END_REF][START_REF] Desgrees-Du-Lou | Contraceptive use, protected sexual intercourse and incidence of pregnancies among African HIV-infected women. DITRAME ANRS 049 Project, Abidjan 1995-2000[END_REF][START_REF] Hoffman | The year-long effect of HIV-positive test results on pregnancy intentions, contraceptive use, and pregnancy incidence among Malawian women[END_REF], although these factors were no more significant in the multivariate analysis. Economic factors such as the level of income of the household have also been shown to play a key role in the fertility intentions of women who are not HIV-infected, notably in Eastern Europe and Asia [START_REF] Mahmood | The desire for additional children among Pakistani women: the determinants[END_REF][START_REF] Ranjan | Fertility behaviour under income uncertainty[END_REF]).

In the same way, disclosure of HIV status to one's main partner and support from the family or one's main partner [START_REF] Kanniappan | Desire for motherhood: exploring HIV-positive women's desires, intentions and decision-making in attaining motherhood[END_REF]) were both associated with women's desire for a child, but only in univariate analyses.

Limitations of the present study include its cross-sectional design, which does not allow analysis of the longitudinal changes in women's desire for a child. There is also a lack Transmission (PMTCT) programs, which may affect their reproductive intentions [START_REF] Kanniappan | Desire for motherhood: exploring HIV-positive women's desires, intentions and decision-making in attaining motherhood[END_REF][START_REF] Peltzer | Family Planning Among HIV Positive and Negative Prevention of Mother to Child Transmission (PMTCT) Clients in a Resource Poor Setting in South Africa[END_REF]. In addition, it must be noted that the categories in the outcome variable are not mutually exclusive. In particular, a woman who is infertile could wish to have a child. However, for a purpose of homogeneity of the study population, the aim of our analysis was to explore the determinants of the desire for a child exclusively among fertile women. In this context, the use of a close question to assess women's desire for a child, without allowing multiple answers, was a deliberate choice.

Finally, the present study is also limited by the lack of information concerning desire for a child among pregnant women (n=23), who were thus excluded from the analyses.

CONCLUSION

The

  Desire for a child among HIV-infected women receiving antiretroviral therapy in Cameroon: results from the national survey EVAL (ANRS 12-116) much for giving us the opportunity of submitting a revised version of our paper entitled "Desire for a child among HIV-infected women receiving antiretroviral therapy in Cameroon: results from the national survey EVAL (ANRS 12-116)" to AIDS Care (manuscript ID AC-2008-12-0580, article type: original article).

  -up of WLHA, in order to pursue the fight against HIV stigma."

  individuals, Cameroon is among those western and central African countries most affected by the AIDS epidemic (UNAIDS 2008). The management of HIV infection is a great challenge for this country, in which 40% of individuals live under the poverty line (defined as 20,000 FCFA per equivalent adult and per month) (2008) and which is characterized by a very young population (with 48% of individuals being less than 49 years old) and a high fertility rate (4.5 ) (WHO-UNAIDS 2008). In 2001, Cameroon initiated a large national program to improve access to ART, based on the decentralisation of HIV care. In June 2007, about 48% of patients eligible for HIV treatment in the country benefited from ART (National AIDS Control Committee 2007). We used data collected in 2007 from a large sample of HIVinfected individuals in Cameroon to explore the socio-economic, clinical and psychosocial characteristics associated with the desire to have a child among ART-treated fertile WLHA of reproductive age in this country. METHODS Patients This study is based on data collected during the national cross-sectional multicenter survey EVAL (ANRS 12-116) 2 which was conducted in Cameroon between September 2006 and March 2007, among a random sample of 3,151 HIV-infected patients aged 21 years or older and diagnosed HIV-positive for at least three months. The EVAL survey took place in 27 HIV care centers located in the 6 of the 10 provinces of Cameroon where the ART scaling-up program was the most advanced (Centre, Littoral, West, South-West, North-West and Far-North). Criteria for selection of the participating care centers included the size of the HIV caseload and the experience in the management of HIV infection (number of years of activity). During the survey, clinical data were collected using medical questionnaires filled in by care providers. Socio-demographic, economic and psychosocial data were collected during face-to-face interviews of patients performed by trained interviewers. The complete design of the survey is detailed elsewhere (Marcellin, Boyer et al. 2008). Our analyses were restricted to 2 The EVAL survey is a research project which aims at evaluating the Cameroonian national program for improving access to ART. It was funded by the French National Agency for Research on AIDS and viral hepatitis (ANRS) and approved by the Ministry of Public Health in Cameroon and the Cameroonian National Ethics Committee.

  reproductive age (<50 years old) who participated in EVAL and were receiving ART at the time of the survey.

  motherhood and sexual activity (age, matrimonial status, number of biological children, frequency of sexual relationships, use of contraception); social relationships (disclosure of seropositivity to the main partner, moral support from the family and/or the main partner); socio-economic status (educational level, area of habitation, being the head of the household, number of adults and children composing the household, number of persons contributing to the household income, professional status, monthly income of the household); clinical characteristics (time since HIV diagnosis, occurrence of diagnosis during pregnancy, CD4 count at last assessment and at initiation of ART, CDC clinical stage); experience with ART (time since initiation of ART, number of self-reported symptoms during the previous four weeks); self-reported physical and mental health-related quality of life (HRQL). Finally, women's knowledge and beliefs about HIV and ART were also considered, using three questions concerning the origin of the questions concerning the modes of transmission of HIV and five questions

  while incorrect or "do not know" answers were rated 0. These rates were then added to obtain the aggregate scores. Higher scores denote better knowledge. Factors associated with the desire for a child were explored using logistic regression models. Each factor was first tested for its association with the desire for a child in a univariate model, excluding categorical variables with classes concerning less than 5% of individuals. Factors with a pvalue <0.25 in these models were then included in a multivariate analysis. Time since HIV diagnosis and the number of children in the household were not included in the multivariate model due to their strong correlation with time since ART initiation and the number of biological children, respectively. In addition, aggregate scores were entered in the multivariate model, preferably to separate variables for knowledge and beliefs about HIV and ART. A forward stepwise selection procedure was used to determine the final multivariate model (entry threshold at p=0.05). The significance level was fixed at α=0.05 for all tests.

  ) to stabilise the development of the disease (Table

  who had been diagnosed HIV-positive during pregnancy tended to report

  discovering their HIV serostatus, and analyzed the evolution of this desire over the twelve months following diagnosis. Results showed a sharp decline in the percentage of women reporting the desire to have a child, from 33% before diagnosis to 15% one week after. No significant change was observed thereafter, which however needs to be paralleled with the relatively short duration of follow-up, and with the fact that only 26% of women in the study initiated ART during follow-up. ART has a positive effect on WLHA's reproductive desires, something which has been highlighted notably by the work ofKaida et al. in the poorresource setting of Uganda. On the basis of data from a cross-sectional survey among 501 adult women aged less than 50 years attending an HIV clinic in that country, they found that women on ART, who represented 45% of their sample, were three times more likely to

  forces) or widespread rumour, closely related to both the fear of getting

  women's knowledge and access to Prevention of Mother-To-Child

1

  during the previous 4 weeks -general symptoms: nausea, vomiting, burning in the stomach, stomach pain, change in the taste of food, bladder or kidney stones, diarrhoea, headache, fatigue, fever, difficulty falling or staying asleep, tickling around the mouth, aching muscles, aching feet and legs (neuropathy), itching skin, hallucinations or dizziness, problems having sexual intercourse and hair or fingernails problems -lipodystrophy symptoms: change in overall body shape, hollow cheeks, larger belly or wider waist, slimmer arms, slimmer buttocks, slimmer legs, veins on the legs becoming visible, larger breasts, accumulation of fat in the neck.

The persistence of the desire for children despite HIV infection has long been described among women living with HIV and AIDS (WLHA) in Africa (Desgrees du Loû, Msellati et al. 1999; Desgrées du Loû and Ferry 2005; Oladapo, Daniel et al. 2005; Desclaux and Desgrées du Loû 2006; Desgrées du Loû and Ferry 2006; Chama, Morrupa et al. 2007), as an answer to psychological, cultural, economic and social demands (Aka Dago-Akribi, Msellati et al. 2001), in a social context which considers motherhood as a cornerstone of a woman's identity (Desgrées du Loû & Ferry, 2006). This cultural demand for child-bearing has been confirmed among migrant WLHA native to Africa, in comparison with WLHA native to Europe

  "

	Revised version:
	"Sub-Saharan Africa remains the region most affected by the global AIDS epidemic, with the
	majority of HIV-infected individuals being women (UNAIDS & WHO, 2007). Many of these
	women are of reproductive age and despite their infection their desire to bear a child remains
	strong.

Table 2 (

 2 please see revised manuscript). These data are shown below:

	Aggregate score ...

from women's reproductive potential (younger age, living in a couple, already being a mother, having frequent sexual relationships), the correlates of this desire comprise, on the one hand, the experience of the HIV disease, through past immunodeficiency and perception of physical HRQL at the time of the survey; and, on the other

	integrated in order to support WLHA's reproductive choices. Counselling and information
	actions should be developed on
	Revised version: "The desire to have a child is frequent among ART-treated WLHA of reproductive age in o r P e e r R e v i e w O n l Cameroon. Apart F y
	13

"The desire to have a child is frequent among ART-treated WLHA of reproductive age in Cameroon. Results suggest that recovery of health thanks to ART has opened up new life perspectives for these women. In a national context of the scaling-up of ART, these data suggest that HIV care and family planning programs should be better integrated in order to support WLHA's reproductive choices. Counselling actions should be developed to support WLHA who desire children to maximise their chances to live a healthy pregnancy and to give birth to a HIV-negative baby." hand, a good knowledge of HIV and ART. In a national context of the scaling-up of ART, these data suggest that HIV care and family planning programs should be better

a regular basis throughout women's follow-up. Future prevention strategies should consider alternative channels of communication and should further encourage the involvement of peers in order to

  support WLHA who desire children, and to maximise their chances to live a healthy pregnancy and to give birth to a HIV-negative baby."

	1
	Desire for a
	F o r
	P
	e
	e r
	R
	e
	v i e
	w
	O n l
	y

child among HIV-infected women receiving antiretroviral therapy in Cameroon: results from the national survey EVAL (ANRS 12-116)

	INTRODUCTION
	Sub-Saharan Africa remains the region most affected by the global AIDS epidemic, with the
	majority of HIV-infected individuals being women (UNAIDS and WHO 2007). Many of
	these women are of reproductive age and despite their infection their desire to bear a child
	Abstract word count: 260 remains strong. The persistence of the desire for children despite HIV infection has long been
	Text word count: 3786 described among women living with HIV and AIDS (WLHA) in Africa (Desgrees du Loû,
	F o r F Msellati et al. 1999; Desgrées du Loû and Ferry 2005; Oladapo, Daniel et al. 2005; Desclaux o r and Desgrées du Loû 2006; Desgrées du Loû and Ferry 2006; Chama, Morrupa et al. 2007),
	P P
	e e
	e r e r
	R R
	e e
	v i e v i e
	w w
	O n l O n l
	y y

as an answer to psychological, cultural, economic and social demands (Aka Dago-Akribi,

[START_REF] Dago-Akribi | Procreation and Child Desire of Women living with HIV in Abidjan, Côte d'Ivoire[END_REF]

, in a social context which considers motherhood as a cornerstone of a woman's identity (Desgrées du

[START_REF] Desgrées Du Loû | Sexualité et procréation confrontées au sida dans les pays du Sud[END_REF]

. This cultural demand for child-bearing has been confirmed among migrant WLHA native to Africa, in comparison with WLHA native to Europe

Table 1 -Characteristics of ART-treated fertile women of reproductive age included in the EVAL survey in Cameroon (n=1,433) % of women or median [IQR] Motherhood, sexual activity and social relationships

 1 desire to have a child is frequent among ART-treated WLHA of

	reproductive age in Cameroon. Apart from women's reproductive potential (younger age,
	living in a couple, already being a mother, having frequent sexual relationships), the
	correlates of this desire comprise, on the one hand, the experience of the HIV disease, through
	past immunodeficiency and perception of physical HRQL at the time of the survey; and, on
	the other hand, a good knowledge of HIV and ART. In a national context of the scaling-up of
	ART, these data suggest that HIV care and family planning programs should be better
	integrated in order to support WLHA's reproductive choices. Counselling and information
	actions should be developed on a regular basis throughout women's follow-up. Future
	prevention strategies should consider alternative channels of communication and should
	further encourage the involvement of peers in order to support WLHA who desire children
	and to maximise their chances to live a healthy pregnancy and to give birth to a HIV-negative
	baby.

Table 2 -Knowledge and beliefs about HIV and ART among ART-treated fertile women of reproductive age included in the EVAL survey in Cameroon (n=1,433) % of women Origin of the disease HIV/AIDS is caused by poverty

 2

	-no 1
	-yes
	-I don't know

of transmission One can be infected by HIV ... ... when kissing a seropositive person

				2 3 1
	-yes IQR = interquartile range			33.8
	-I don't know			26.5
	ARV stabilise the development of HIV -no 1 correct answer.		0.8
	-yes 1			92.8
	-I don't know			6.3
	ARV decrease the risk of becoming ill
	-no			8.1
	-yes 1			83.9
	-I don't know			8.0
	A person who takes ARV cannot transmit HIV
	-no 1			68.9
	F o r -I don't know -yes A person who takes ARV and feels better can stop treatment -no 1 -yes -I don't know F o r F o r	11.1 20.0 87.0 3.3 9.7
	P Aggregate score (range: 0 to 5) median [IQR] P P		4 [3; 5]
	e e e
	-no 1 -yes -I don't know	e r e r e r R R R	54.6 17.1 28.3
	... during unprotected sexual relationships -no -yes 1 -I don't know ... after a mosquito bite -no 1	e e e v i e v i e v i e	0.4 96.4 3.2 61.1
	-yes -I don't know ... during a blood transfusion		w w w	17.4 21.5
	-no -yes 1 -I don't know ... when drinking from the same glass as a seropositive person -no 1 -yes -I don't know O 94.7 1.6 3.7 80.5 n l O n l O n l 5.3 14.2 y y y
	Babies from seropositive women can be infected
	during pregnancy or delivery
	-no			3.1
	-yes 1			87.8
	-I don't know			9.1
	Aggregate score (range: 0 to 6)
	median [IQR]			5 [4; 6]
	Mechanisms of action of antiretrovirals (ARV)
	ARV can cure HIV
	-no 1			39.7

Table 3 -Factors associated with desire for a child among ART-treated fertile women of reproductive age included in the EVAL survey in Cameroon

 3

	Univariate analyses	Multivariate analysis
	p-value	OR [95% CI]	p-value	OR [95% CI]

No. of children in the household

	<0.0001	0.88 [0.84; 0.92]

No. of persons contributing to the household income*

	F o r
	P
	e
	e r
	R
	e
	v i e
			w
	-1 person (ref.) -2 persons or more Professional status* -inactive (ref.)	0.014 0.004	1 1.32 [1.06; 1.65] 1 O n l
	-active Monthly income of the household*		0.72 [0.58; 0.90] y
	-OR for a 1 log 10 increment	0.01	1.40 [1.08; 1.81]
	Clinical characteristics
	Time since HIV diagnosis
	-OR for a 12-month increment	0.02	0.995 [0.990; 0.999]
	CD4 count at initiation of ART <200 cells/mm 3 *
	-no (ref.)	0.03	1	0.002	1
	-yes		1.33 [1.02; 1.74]		1.73 [1.22; 2.44]
	CDC stage C
	-no (ref.)	0.37	1
	-yes		0.91 [0.73; 1.12]
	Experience with ART

http://mc.manuscriptcentral.com/ac-phm-vcy Health Sciences

Resources for HIV/AIDS and Sexual and Reproductive Health Integration site, http://www.hivandsrh.org/

ACKNOWLEDGEMENTS

We would like to thank the French National Agency for Research on AIDS and viral hepatitis (ANRS) which funded this research and the Cameroonian Ministry of Health for its support in the implementation of the EVAL survey. We would also like to thank all the patients who accepted to participate in the survey as well as healthcare providers for their strong involvement in the data collection stage.

FUNDING

The French National Agency for Research on AIDS and viral hepatitis (ANRS) funded the EVAL survey (ANRS 12-116) research program and the Cameroonian Ministry of Public Health supported its execution.

ABSTRACT

The majority of HIV-infected people in sub-Saharan Africa are women, many of reproductive age. Cameroon is severely hit by the AIDS epidemic and has developed a large national program for improving access to antiretroviral treatment (ART). The reproductive intentions of women living with HIV/AIDS (WLHA) who obtain access to ART in this country remain poorly documented. Our study aimed at exploring factors associated with the desire to have a child among 1,433 ART-treated fertile WLHA aged <50. Analyses were based on data collected during the national cross-sectional survey EVAL , which was conducted between September 2006 and March 2007 in 27 HIV care centers in Cameroon.

Logistic regression was used to explore factors associated with women's desire to have a child, defined as reporting the wish to have a/another child.

A total of 791 women (55%) reported the desire to have a child. After adjusting for age, matrimonial status, number of biological children and sexual activity, the main factors independently associated with this desire in a multivariate analysis were having a good physical health-related quality of life (HRQL) (1.02[1.01-1.03] for a one-point increment on the SF-12 scale) and a CD4 count at ART initiation <200 cells/mm 3 (1.7[1.2-2.4]). As a conclusion, the desire to have a child is frequent among ART-treated WLHA in Cameroon.

HIV care and family planning programs should be integrated more thoroughly in order to support WLHA's reproductive choices. Keywords: antiretroviral therapy; desire for a child; Africa.

DISCLOSURE OF INTERESTS

There is no conflict of interest.

DETAILS OF ETHICS APPROVAL

The research was approved by the Ministry of Public Health in Cameroon and the Cameroonian National Ethics Committee.


Explaining perceived ability among older people to provide care as a result of HIV and AIDS in South Africa

Keywords: Older people, Caregiving, South Africa, HIV/AIDS Older people, care-giving, South Africa, HIV, AIDS

In South Africa, older people have become the primary caregivers of children and grandchildren infected or affected by HIV and AIDS. This study explores the determinants of the perceived ability to care for children and grandchildren in the domains of providing nursing care, communicating with (grand) children, generating income, and to relax. Structured one-on-one interviews were conducted among 409 isiXhosa speaking older people in two sites in the Eastern Cape Province of South Africa. Results showed that perceived ability among older people to provide nursing care was primarily dependent on the level of knowledge on accessing grants and personal norm towards providing care. Perceived ability to communicate effectively with children and grandchildren was most strongly predicted by a positive attitude towards communication and perceived ability to provide income was influenced by a more negative attitude towards people living with HIV or AIDS. Perceived ability to relax was dependent on more negative attitudes towards communication, lower perceived responsibility to provide income, and a higher perceived behaviour control over providing nursing care. The findings of this study add relevant information to understanding the psychosocial context in which older people provide HIV and AIDS related care and support the development of targeted programmes to assist older people in their role as caregiver.

 , 2007). As health services are unable to accommodate the increasing numbers of patients, the care of sick adult children and orphaned grandchildren is primarily left in the hands of elderly parents [START_REF] Ntozi | AIDS in Uganda: How has the household coped with the epidemic? The continuing African HIV/AIDS epidemic[END_REF]Williams & Tumwekwase, 2001), mainly elderly women [START_REF] Madhavan | Fosterage patterns in the age of AIDS: continuity and change[END_REF][START_REF] Ssengonzi | The impact of HIV/AIDS on the living arrangements and wellbeing of elderly caregivers in rural Uganda[END_REF] who often have little or no support to assume responsibilities for the physical, emotional and economic needs of their dependents [START_REF] Freeman | Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers[END_REF][START_REF] Knodel | Researching the impact of the AIDS epidemic on older-age parents in Africa: Lessons from studies in Thailand[END_REF][START_REF] Ntozi | AIDS in Uganda: How has the household coped with the epidemic? The continuing African HIV/AIDS epidemic[END_REF]Nyambedha, Wandibba, & Aagaar-Hansen, 2003;[START_REF] Schatz | Taking care of my own blood": Older women's relationships to their households in rural South Africa[END_REF][START_REF] Ssengonzi | The plight of older persons as caregivers to people infected/affected by HIV/AIDS: Evidence from Uganda[END_REF]Williams & Tumwekwase, 2001).

In South Africa, the situation of grandparents caring for their adult and grandchildren is however not new. Its history of Apartheid and labour migration systematically divided African families by recruiting men and women to the centres for employment [START_REF] Chazan | Seven 'deadly' assumptions: Unravelling the implications of HIV/AIDS among grandmothers in South Africa and beyond[END_REF][START_REF] Madhavan | Fosterage patterns in the age of AIDS: continuity and change[END_REF][START_REF] Marais | Buckling: The impact of AIDS in South Africa[END_REF]. Families were in a reciprocal exchange while older people facilitated the economic migration of younger adults by caring for their grandchildren and safeguarding the family land and assets [START_REF] Hosegood | HIV/AIDS and older people in South Africa[END_REF]. What is new to this situation is that AIDS has undermined the traditional reciprocal care arrangements as migrant parents fall ill and die, and therefore can no longer provide remittances to the grandparents caring for their children [START_REF] Chazan | Seven 'deadly' assumptions: Unravelling the implications of HIV/AIDS among grandmothers in South Africa and beyond[END_REF][START_REF] Madhavan | Fosterage patterns in the age of AIDS: continuity and change[END_REF][START_REF] Marais | Buckling: The impact of AIDS in South Africa[END_REF]. Besides, parents 3 themselves may move back home to be nursed [START_REF] Clark | Returning home to die: Circular labour migration and mortality in South Africa[END_REF][START_REF] Marais | Buckling: The impact of AIDS in South Africa[END_REF][START_REF] Schatz | Taking care of my own blood": Older women's relationships to their households in rural South Africa[END_REF]. As a result, older people have to endure the emotional, physical, financial and social costs that arise from their role as caregivers (e.g., [START_REF] Freeman | Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers[END_REF][START_REF] Ntozi | AIDS in Uganda: How has the household coped with the epidemic? The continuing African HIV/AIDS epidemic[END_REF]Nyambedha, Wandibba, & Aagaar-Hansen, 2003;[START_REF] Schatz | Taking care of my own blood": Older women's relationships to their households in rural South Africa[END_REF][START_REF] Ssengonzi | The plight of older persons as caregivers to people infected/affected by HIV/AIDS: Evidence from Uganda[END_REF].

To support older people in their role as caregivers, an understanding of their beliefs and needs with respect to providing care is required. Existing research has identified potential factors related to the care-giving roles of older caregivers [START_REF] Freeman | Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers[END_REF][START_REF] Ssengonzi | The plight of older persons as caregivers to people infected/affected by HIV/AIDS: Evidence from Uganda[END_REF][START_REF] Ssengonzi | The impact of HIV/AIDS on the living arrangements and wellbeing of elderly caregivers in rural Uganda[END_REF]Williams & Tumwekwase, 2001), but there is a lack of evidence regarding the relative contributions of these factors in explaining the perceived ability to provide care. This paper therefore aims to identify the psychological correlates of the perceived ability of older caregivers to provide different aspects of care which will impact on the development of targeted programmes to assist older caregivers. Further, the results of this case study in combination with results from other studies adds to a better understanding of the psychosocial context within which older caregivers provide HIV and AIDS related care.

Method

Study Design

This quantitative study consisted of a cross-sectional survey among 409 isiXhosa speaking elderly caregivers of 60 years and older, who reported caring for their sick adult children and/or grandchildren as a result of HIV and AIDS. Eighteen trained community health workers, nine from Motherwell and nine from Uitenhage, all first language isiXhosa speaking women were recruited onto the study. They were responsible for inviting the participants who received services from the Age-in-Action club to participate in the study. Through a snow-ball effect some older persons in the community became aware of the study and showed their interest to participate. They were included if they matched the inclusion criteria.

The community health workers conducted one-on-one interviews with the participants. Questions and response options were read out to the participants and answers were recorded on paper questionnaires. The interviews were conducted in isiXhosa, the first language of both interviewers and participants. Each interview took about one hour and twenty minutes. Interviews took place at the homes of the participants where they usually receive the services provided by the Age-in-Action club. As the health workers were known to the participants and they usually visited them in their homes there was minimal concern that these visits would arouse suspicion or curiosity from neighbours and family.

Detailed information about the content, procedures and confidentiality of the study was provided to the participants both verbally and in writing in isiXhosa before consent was obtained. Ethical approval for the study was granted by the South African Medical Association Ethics Committee. The measurement instrument was based on existing literature about older people as providers of care, foregoing qualitative and quantitative research (Boon et al., 2009a;[START_REF] Boon | Challenges for older caregivers in a time of HIV and AIDS: A qualitative analysis[END_REF][START_REF] Freeman | Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers[END_REF][START_REF] Reddy | Inkala ixinge etyeni: Trapped in a difficult situation[END_REF][START_REF] Nyambedha | Retirement lost"the new role of the elderly as caretakers for orphans in Western Kenya[END_REF][START_REF] Ssengonzi | The plight of older persons as caregivers to people infected/affected by HIV/AIDS: Evidence from Uganda[END_REF]Williams & Tumwekwase, 2001), and general predictors of human behaviour derived from social cognition models [START_REF] Connor | Predicting health behaviour: A social cognition approach[END_REF]. Demographic questions concerning age, gender, relationship status, monthly income and number of dependents were included.

Measurement Instrument

All psychological measures were based on Likert-type items with three or five response options. For each measure, scores on items that showed sufficient internal consistency (Cronbach's alpha [α] > .60) were averaged into one single index. Higher scores reflect a stronger presence of the concerning variable. Based on previous research (Boon et al., 2009a;[START_REF] Reddy | Inkala ixinge etyeni: Trapped in a difficult situation[END_REF], four care abilities were identified that served as outcome variables;

(1) the perceived ability to provide nursing care;

(2) the perceived ability to effectively communicate with children in different generations;

(3) the perceived ability to provide an income for the household, and (4) the perceived ability to take time to relax. An overview of the psychological measures, including sample items and the Cronbach's alpha, is presented in Table 1.

[Table 1 about here]

Data analysis

In the main analyses, bivariate correlations were calculated for the psychosocial variables. As eighteen interviewers were responsible for data collection, all participants were nested within a certain interviewer. the perceived ability to communicate with children and grandchildren, followed by the ability to provide nursing care and the ability to relax. The lowest mean score was found for the older person's perceived ability to provide an income.

[Table 2 about here]

Table 3 displays the estimates of fixed effect (β), standard error (SE), and explained variance (R 2 ) for each dimension of perceived caring ability.

[Table 3 about here]

Perceived ability to provide nursing care

To explain the variance in providing nursing care, unique contributions were found for knowledge on accessing grants, personal norm towards providing care, attitude towards people living with HIV or AIDS, perceived care burden, and subjective norm towards providing care. Higher scores on these variables were related to more positive perceptions of the ability to provide nursing care. In addition, significant interactions between site of study and personal norm towards providing care, knowledge on accessing grants, and perceived behavioural control over providing nursing care were found respectively. Simple effect analyses showed that among those living in Uitenhage personal norm towards providing care (β = .21; SE = .04; p < .001) and knowledge on accessing grants (β = .20; SE = .04; p < .001) were positively associated with the ability to provide nursing care, whereas in Motherwell no significant associations were found for both concepts (β = -.14; SE = .08; p > .05

and β = -.02; SE = .04; p > .05, respectively). Furthermore, the interaction pattern between site and perceived behaviour control over providing nursing care showed a positive relation to the perceived ability to provide care in Motherwell (β = .17; SE = .06; p < .01), whereas in Uitenhage no significant relationship was found (β = -.01; SE ). The total model explained 41% of the total variance in perceived ability to provide nursing care.

Perceived ability to communicate effectively with dependents

The perceived ability to communicate with dependents was explained with unique contributions from attitude towards communication, attitude towards people living with HIV or AIDS, perceived behaviour control over providing nursing care, knowledge on accessing grants and subjective norm towards providing care. Higher scores on these variables were associated with higher scores in the outcome variable.

Furthermore, the association between knowledge on accessing grants and perceived ability to communicate effectively with dependents differed for Motherwell and Uitenhage. In Uitenhage knowledge on accessing grants was found to be significantly correlated with the ability to communicate effectively with dependents (β = .06; SE = .02; p < .01), whereas in Motherwell no significant association was found (β = -.02; SE = .02; p > .05). The total model explained 49% of the variance in the perceived ability to effectively communicate with dependents.

Perceived ability to provide income

A higher perceived ability to provide income was associated with a more negative attitude towards people living with HIV or AIDS, a more positive attitude towards communication, a more positive personal norm towards providing care, a higher knowledge on accessing grants, and a more positive subjective norm towards providing care. Furthermore, interactions with site were found for perceived feelings of helplessness, attitude towards people living with HIV and AIDS, perceived responsibility to provide income, and knowledge on accessing grants. In Motherwell, perceived feelings of helplessness (β = .29; SE = .14, p < .05), and perceived responsibility to provide income (β = .23; SE = .07, p < .01) were positively

Perceived ability to relax

Attitude towards communication, perceived responsibility to provide income, perceived behaviour control over providing nursing care, attitude towards relaxation, subjective norm towards providing care, and knowledge on accessing grants uniquely contributed to the prediction of perceived ability to relax. In addition, interaction effects were found between site and, respectively, attitude towards communication, perceived responsibility to provide income, perceived behaviour control over providing nursing care, and knowledge on accessing grants. In both Motherwell (β =

.12; SE = .09, p > .05) and Uitenhage (β = -.20; SE = .10, p > .05), attitude towards communication was not significantly related to perceived ability to relax. In Uitenhage, both perceived behaviour control over providing nursing care (β = .16; SE = .05, p < .001) and knowledge on accessing grants (β = .15; SE = .03, p < .001) were positively associated with perceived ability to relax; whereas attitude towards providing income was negatively related to perceived ability to relax (β = -.22; SE = .07, p < .001). In Motherwell, no significant associations were found between

Discussion

In the present study, theoretical psychosocial constructs such as attitudes, perceived behaviour control over providing nursing care, personal and subjective norms towards providing care and knowledge on accessing grants were important predictors across the four ability dimensions. In addition, different correlates emerged for the different dimensions of caring ability that were explored. The most important predictors of caregivers' perceived ability to provide nursing care were more knowledge on accessing grants and a more positive personal norm towards providing care. Perceived ability to communicate effectively with children and grandchildren was predicted most strongly by a more positive attitude towards communication. A more negative attitude towards people living with HIV or AIDS and a more positive attitude towards communication were the primary predictors for perceived ability to provide income. Only in Motherwell feelings of helplessness were positively associated with perceived ability to provide income. The main predictors of perceived ability to relax were a more negative attitude towards communication, lower perceived responsibility to provide income and a higher perceived behaviour control over providing nursing care.

Somewhat counterintuitive was the finding that a more negative attitude towards people living with HIV or AIDS contributed to a higher perceived ability to provide income. This finding could possibly be explained by the impact that interpersonal or environmental variables have on the ability to provide income. 12 Factors such as for example a bad relationship between the sick person and the caregiver, the reason why the older person took on the care-giving role [START_REF] Nyambedha | Retirement lost"the new role of the elderly as caretakers for orphans in Western Kenya[END_REF] or fear of disclosure and stigma from the community [START_REF] Moore | Older poor parents who lost an adult child to AIDS in Togo, West Africa: A qualitative study[END_REF][START_REF] Mwinituo | Stigma associated with Ghanaian caregivers of AIDS patients[END_REF] could have possibly contributed to a more negative attitude towards people living with HIV or AIDS. However these factors might not be restricting an older person's ability to provide income, especially when support from family or community members [START_REF] Orner | Psychosocial impacts on caregivers of people living with AIDS[END_REF] is available. A negative attitude towards people living with HIV and AIDS could on the other hand also lead to social exclusion of the person infected with HIV as well as the family caregiver [START_REF] Mwinituo | Stigma associated with Ghanaian caregivers of AIDS patients[END_REF], resulting in less support from the community. The counterintuitive finding that a more negative attitude towards communication and a more negative attitude towards providing income contributed to higher perceived ability to relax could possibly be explained by older people not perceiving themselves responsible to provide income and to communicate effectively with children and grandchildren and therefore allow themselves time to relax.

Overall, by determining the relative importance of social cognitive constructs in understanding care-giving related behaviours these findings add relevant information to existing research that mostly used qualitative study designs to determine the needs, consequences and challenges of older caregivers (e.g. Boon et al., 2009a;[START_REF] Schatz | Caring and contributing: The role of older women in rural South African multi-generational households in the HIV/AIDS era[END_REF][START_REF] Ssengonzi | The plight of older persons as caregivers to people infected/affected by HIV/AIDS: Evidence from Uganda[END_REF][START_REF] Ssengonzi | The impact of HIV/AIDS on the living arrangements and wellbeing of elderly caregivers in rural Uganda[END_REF]Williams & Tumwekwase, 2001). Nevertheless one should be cautious in generalising the AIDS. Furthermore, the differences in findings we found between demographically comparable sites emphasise the importance of a detailed needs assessment and analysis of important predictors of outcome variables for every new study context. In addition to differences between sites, differences might also be found within sites among subpopulations, for example when comparing grandparents caring for only grandchildren versus grandparents caring for both adult and grandchildren.

To

  Explaining perceived ability among older people to provide care as a result of HIV and AIDS in South Africa among older people to provide care as a result of HIV and AIDS in South Africa In the past few years the HIV and AIDS epidemic has become one of the most important public health challenges in South Africa. A recent report by the Department of Health indicated that 5.4 million South Africans were infected with HIV with the rate of infection being highest amongst people between the ages of 15 and 49 years (Department of Health

  perceived ability to provide income. In Uitenhage no significant associations were found for both concepts (β = -.13; SE = .08; p > .05 and β = .01; SE = .05; p > .05). In Uitenhage, attitude towards people living with HIV and AIDS was negatively related to perceived ability to provide income (β = -.29; SE = .06, p < .001), which was not found in Motherwell (β = .09; SE = .09; p > .05). Finally, in Motherwell, knowledge about accessing grants was negatively associated with perceived ability to provide income (β = -.08; SE = .03, p < .05), while in Uitenhage the association was positive (β = .06; SE = .03, p < .05). Forty-one percent of the variance in perceived ability to provide income could be explained by the correlates in the model.

  over providing nursing care (β = .00; SE = .04, p > .05), knowledge on accessing grants (β = .03; SE = .03, p > .05), attitude towards providing income (β = .05; SE = .06, p > .05) and perceived ability to relax. The total model accounted for 37% of the variance in perceived ability to relax.

  findings to other populations as this study was conducted among a convenience sample of older people in the Eastern Cape of South Africa. More case studies are needed to confirm our findings and extend the current knowledge base of psychosocial correlates of the ability to provide home care in the context of HIV and

  Historically the Eastern Cape is home to a predominantly isiXhosa speaking population and portrays a culture rich in traditions. The study sites of Motherwell and Uitenhage consist of informal settlements and are part of the Nelson Mandela

	As no detailed population statistics were available for the study sample from
	which a probability sample could be extracted, community health workers were
	approached to provide access to caregivers with whom they had worked with
	Metropolitan Municipality that has a population of just over 1 million people extensively. The community health workers were employed by Age-in-Action, a local
	(Statistics South Africa, 2007). The majority of the population is African, younger non-governmental organisation and partner in this study.
	than 30 years of age, do not have a secondary school qualification and live below the
	F o r Household Subsistence Level poverty line on an annual income of R19200 (about 2313 USD) (Department of Provincial and Local Government South Africa, 2008; F o r
	P e Nelson Mandela Bay Municipality, 2008). P As with many informal settlements in the Eastern Cape, Motherwell and e
	e r Uitenhage are faced with high rates of unemployment, poverty and service delivery backlogs (Nelson Mandela Bay Municipality, 2008) and a high prevalence of HIV e r
	R infection. In 2006, 29 percent of the antenatal clinic attendees were found to be HIV R
	e v i e w e positive (Department of Health in South Africa, 2007). In the Nelson Mandela Metropolitan HIV and AIDS was most prevalent among the African population. The v i e African population had the largest number of maternal (81.2%) and paternal (70.3%) orphans (Development Partners, 2007). w
	O n l y In total 200 participants from Uitenhage and 209 from Motherwell completed Participants O n l the survey. Eight participants did not fulfil the inclusion criteria and were removed y
	from the analyses. The inclusion criteria were that participants spoke isiXhosa, were
	over the age of 60 and were looking after one or more children and/or grandchildren.
	The age of 60 was maintained as cut-off point as this is the pensionable age for
	women in South Africa. This resulted in a total sample of 401 elderly caregivers.
	Study Setting Procedure
	4

The elderly caregivers were from Motherwell and Uitenhage, two districts in the Eastern Cape of South Africa.

Table 1 :

 1 conclude, this study has improved the understanding of the most important variables impacting on the care-giving ability of older people in the context of HIV and AIDS. By providing a core list of possible intervention targets (e.g. attitudes, personal norms towards providing care, perceived behaviour control over providing nursing control and knowledge on accessing grants) it provides valuable information for the systematic design and evaluation of educational interventions to assist older people in coping with their care-giving concerns. Overview of scale measures

	F o r
	P
	e
	e r
	R
	e
	v i e
	w
	O n l
	y

Table 2 :

 2 Bivariate correlations between study variables(N = 401)

			1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17
	1	Perceived ability to provide nursing care	-
	2	Perceived ability to communicate effectively with dependents	.57***	-
	3	Perceived ability to provide income	.55***	.50***	-
	4	Perceived ability to relax	.56***	.56***	.57***	-
	5	Perceived care burden	.11*	-.12*	.12*	-.09	-
	6	Perceived behaviour control over daily care activities	.15**	.18***	.08	.22***	-.20***	-
	7	Perceived feelings of helplessness	-.01	-.19***	-.13*	.02	.04	.17***	-
	8	Self-care	.08	.05	.12*	.06	.07	.10	.02	-
	9	Attitude towards people living with HIV
		or AIDS	.39***	.46***	.26***	.34***	-.07	.10*	-.18***	.09	-
	10	Attitude towards communication	.39***	.60***	.39***	.33***	-.06	.13**	-.24***	-.01	.34***	-
	11	Perceived behaviour control over
		providing	.45***	.37***	.38***	.40***	.08	.06	-.02	-.02	.12*	.28***	-
		nursing care
	12	Perceived responsibility to provide income	.29***	.28***	.48***	.32***	.01	-.03	-.19***	-.14**	.14**	.35***	.59***	-
	13	Attitude towards relaxation	-.06	-.03	.26***	.17***	.03	-.14**	-.15**	.02	.05	-.02	.19***	.36***	-
	14	Personal norm towards providing care	.28***	.22***	.40***	.25***	.08	-.06	-.11*	-.02	.12*	.27***	.43***	.59***	.22***	-
	15	Subjective norm towards providing care	.55***	.57***	.56***	.60***	-.01	.18***	-.11*	.10	.49***	.42***	.22***	.25***	.11*	.26***	-
	16	Knowledge on HIV and AIDS	.26***	.35***	.25***	.29***	-.10*	.22***	-.05	.09	.37***	.32***	.00	.09	.02	.10*	.42***	-
	17	Knowledge on accessing grants	.31***	.23***	.17***	.27***	.20***	.09	-.04	.14**	.24***	.13**	.22***	.01	-.12*	.05	.19***	.13**	-
		Mean	3,94	4,11	3,67	3,93	2,07	1,76	1,73	3,88	4,47	3,61	4,03	3,90	4,39	4,18	2,14	3.61	2.92
		Standard deviation	0,82	0,53	0,70	0,66	0,29	0,53	0,38	0,53	0,40	1,03	0,76	0,92	2,88	0,85	0,38	2.81	1.17
		Minimum	1	1	1	1	1	1	1	1	1	1	1	1	-10	1	1	0	0
		Maximum	5	5	5	5	3	3	3	5	5	5	5	5	10	5	3	10	6
		* p < .05 ** p < .01	*** p < .001

http://mc.manuscriptcentral.com/ac-phm-vcy Health Sciences

If yes, how much of a burden is this for you? 1 = yes 0 = no 1 = no burden at all 2 = not so much of a burden 3 = a heavy burden

29

.97