1090827 research-article2022 WHE0010.1177/17455057221090827Women’s HealthHuertas-Zurriaga et al. HIV and Women’s Health: Where Are We Now - Review Women’s Health Reproductive decision-making of Volume 18: 1­–15 © The Author(s) 2022 Article reuse guidelines: Black women living with HIV: sagepub.com/journals-permissions DOI: 10.1177/17455057221090827 https://doi.org/10.1177/17455057221090827 A systematic review journals.sagepub.com/home/whe Ariadna Huertas-Zurriaga1,2, Patrick A Palmieri2,3,4,5 , Mariela P Aguayo-Gonzalez2,6,7 , Karen A Dominguez-Cancino2,8,9 , Cristina Casanovas-Cuellar1,6 , Kara L Vander Linden10,11, Sandra K Cesario5,12 , Joan E Edwards5,12 and Juan M Leyva-Moral2,5,6,7 Abstract Background: Black women living with HIV account for a higher proportion of new HIV diagnoses than other groups. These women experience restricted access to reproductive services and inadequate support from healthcare providers because their position in society is based on their sexual health and social identity in the context of this stigmatizing chronic disease. By recognizing the analytical relevance of intersectionality, the reproductive decision-making of Black women can be explored as a social phenomenon of society with varied positionality. Objective: The purpose of this review was to synthesize the evidence about the reproductive decision-making of Black women living with HIV in high-income countries from the beginning of the HIV epidemic to the present. Methods: This systematic review was guided by the JBI evidence synthesis recommendations. Searches were completed in seven databases from 1985 to 2021, and the review protocol was registered with PROSPERO (CRD420180919). Results: Of 3503 records, 22 studies were chosen for synthesis, including 19 observational and three qualitative designs. Nearly, all studies originated from the United States; the earliest was reported in 1995. Few studies provided detailed sociodemographic data or subgroup analysis focused on race or ethnicity. Influencing factors for reproductive decision- making were organized into the following seven categories: ethnicity, race, and pregnancy; religion and spirituality; attitudes and beliefs about antiretroviral therapy; supportive people; motherhood and fulfillment; reproductive planning; and health and wellness. Conclusion: No major differences were identified in the reproductive decision-making of Black women living with HIV. Even though Black women were the largest group of women living with HIV, no studies reported a subgroup analysis, and few studies detailed sociodemographic information specific to Black women. In the future, institutional review boards should require a subgroup analysis for Black women when they are included as participants in larger studies of women living with HIV. 1 8  rea de Suport a la Recerca en Cures, Hospital Universitari Germans À  scuela de Enfermería, Universidad Científica del Sur, Lima, Perú E 9 Trias i Pujol, Barcelona, Spain Escuela de Salud Pública, Universidad de Chile, Santiago de Chile, 2 Evidence-Based Health Care South America: A JBI Affiliated Group, Chile 10 Lima, Peru Department of Research, Saybrook University, Pasadena, CA, USA 3 11 South American Center for Qualitative Research, Universidad Glaser Center for Grounded Theory, Institute for Research and Norbert Wiener, Lima, Perú Theory Methodologies, Poway, CA, USA 4 12 College of Graduate Health Studies, A.T. Still University, Kirksville, Nelda C. Stark College of Nursing, Texas Woman’s University, MO, USA Houston, TX, USA 5 Center for Global Nursing, Texas Woman’s University, Houston, TX, USA Corresponding author: 6 Department d’Infermeria, Facultat de Medicina, Universitat Autònoma Patrick A Palmieri, South American Center for Qualitative Research, de Barcelona, Barcelona, Spain Universidad Privada Norbert Wiener, Av. Arequipa 444, Piso 4, Torre 7 Grupo de Investigación Enfermera en Vulnerabilidad y Salud (GRIVIS), 2, Lima 15046, Peru. Universitat Autònoma de Barcelona, Barcelona, Spain Email: patrick.palmieri@jbisa.org Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Women’s Health Keywords Blacks, contraception, decision-making, developed countries, high-income countries, HIV, organization for economic co- operation and development, racial groups, reproduction, reproductive behavior, systematic review, women’s health Date received: 31 October 2021; revised: 3 March 2022; accepted: 9 March 2022 Introduction reproductive coercion from healthcare institutions,30 being advised to avoid pregnancy,31,32 be sterilized,32–34 or have Women living with HIV encounter different challenges an elective abortion.32,35,36 Despite decades of work to than men in their daily lives because of their role in develop women-centered approaches to care for women reproductive health. For most women, motherhood is an living with HIV,37,38 stigma remains a major problem in important social identity1 that gives meaning to life.2 most healthcare settings.39,40 This situation is even more Reproductive decision-making for women has been complex since women living with HIV have to concur- described as passive,3 implicit,4 automatic,5 or something rently manage family pressures and community expecta- that just happens.6 However, the decision to have a child tions when engaging in reproductive decision-making.41,42 is heavily influenced by societal norms and community expectations. Hadley7 suggested the pronatal norm is firmly rooted in sociocultural structures, where mother- hood is an inevitable decision for women. As such, moth- Background erhood is considered part of the normal course of The HIV epidemic disproportionately affects some popu- heterosexual life.3,8–10 lations of women more than others as evidenced by differ- Decisions about pregnancy for women living with HIV ences in race, ethnicity, sexual orientation, and are often complex.11 For instance, HIV impacts maternal socioeconomic characteristics.43 For example, Black mortality during pregnancy by increasing the risk of com- women account for a higher proportion of new HIV diag- plications and the potential for adverse perinatal outcomes, noses than other races.44,45 In the United States, Black such as postpartum hemorrhage and puerperal sepsis. In women living with HIV represent about 13% of the female general, pregnant women are also more susceptible to population but account for 55% of female HIV diagno- infections.12–14 At the same time, women living with HIV ses.46 Similarly, Black women of African ethnicity in the have to cope with stigma and discrimination from their United Kingdom represent 66% of female HIV diagnoses; families, social networks, and the larger community,15 White women represent only 21% of diagnoses.47 In addi- mostly because misinformation and prejudice persist in tion to managing their HIV infection, Black women must healthcare institutions.16–18 Consequently, women living also navigate issues related to racism and discrimination,48 with HIV and contemplating pregnancy have additional which contribute to their heightened feeling of stigma.49 concerns about their baby being born with HIV, their Therefore, Black women living with HIV are more likely health during the pregnancy, and their potential death to experience depression, posttraumatic stress disorder, before their child becomes an adult.14,19 and substance abuse.50 Because of increased access to safe contraceptive meth- Healthcare experiences are shaped by interconnected ods, nearly, 80%20 of women living with HIV of childbear- and interdependent social conditions.51 For decades, dis- ing age have the choice to avoid pregnancy.21 Furthermore, crimination has caused an inequitable distribution of more effective antiretroviral therapies can maintain an healthcare resources52 that continues to disadvantage undetectable viral load, so women living with HIV can Black women living with HIV.53 Because they encounter choose pregnancy and have a less than a 1% risk of mother- restricted access to reproductive services and inadequate to-child transmission.22 The availability and access to support from healthcare providers when making reproduc- effective antiretroviral therapies in high-income countries tive decisions,48 these women often access healthcare later allows women living with HIV to have safe and successful or with less frequency for pregnancy-related care. For pregnancies.23 For this reason, these women require guid- Black women, race also intersects with other social char- ance from their healthcare providers about reproductive acteristics that generate oppression with power gradi- health that is tailored to their reality of living with HIV. ents.54,55 As such, oppression has resulted in involuntary Healthcare providers generally avoid managing the sterilization of Black women living with HIV.56,57 In addi- sexual health of patients during primary care visits.24 In the tion, gendered racism has relegated Black women to the case of women living with HIV, psychosocial aspects of background of HIV research, specifically in relation to clinical care are rarely addressed by providers during con- reproductive decision-making.58 As a result, the research versations about reproductive desires and sexual health literature perpetuates the privilege of being a White, het- needs.25–29 Furthermore, women living with HIV report erosexual, educated, and upper-middle-class woman. Huertas-Zurriaga et al. 3 Intersectionality Methods Black women living with HIV are positioned in society in This systematic review of the scientific literature was relation to their sexual health, and their social identity is guided by the Joanna Briggs Institute evidence synthesis often contextualized by a stigmatizing chronic disease.59 recommendations.74,75 The reporting criteria followed the However, their social identity also includes multiple Preferred Reporting Items for Systematic Reviews and sources of oppression, such as race, ethnicity, gender, Meta-Analyses (PRISMA) statement,76 and the protocol income, education, health status, and other factors60,61 guiding this review was registered with PROSPERO related to “racialized and gendered subjects” marginalized (CRD42018091971), the International Prospective by power structures.59 Intersectionality offers a lens to see Register of Systematic Reviews.77 where this “power comes and collides, where it interlocks Research studies with quantitative, qualitative, and and intersects.”62 Within the narrow context of reproduc- mixed-methods designs published in peer-reviewed scien- tive justice,63 power structures can oppress decision-mak- tific journals that addressed reproductive decisions in ing64 and marginalize people living with HIV.65 For these women living with HIV were included in this review. reasons, intersectionality has analytical relevance for sen- Studies reporting any type of literature review were sitive topics, such as reproductive health,66,67 that can be excluded, except when the review included a meta-synthe- synthesized from the literature to identify the social expe- sis or meta-analysis reporting data specific to Black riences resulting in marginalization68 and the positional women living with HIV. Review papers and graduate dis- variability within and between groups69 causing health sertations and theses were excluded, but their reference inequities.70 lists were assessed for studies meeting the inclusion crite- ria. Editorials and commentaries, guidelines, reports, and narrative policy papers were also excluded from the Rationale for the review review. Randomized control trials focused exclusively on The majority of reproductive decision-making literature the efficacy of antiretroviral drugs and epidemiological focuses on women living with HIV without reporting the studies not focused on the reproductive decision-making experiences of Black women living with HIV in high- process were excluded as well. income countries, such as Canada,71 the United Kingdom,72 For this study, high-income countries were determined by and the United States.73 Although the experiences of Black membership in the Organization for Economic Co-operation women included in this review are described by their and Development (OECD).42 The 35 member countries of shared social context of living with HIV,69 the intersection the OECD78 have similar compliance with international of their different social identities are largely unknown in laws, adherence to human rights conventions, and adoption the reproductive health literature. As such, the findings of of evidence-based clinical practice guidelines for HIV/ this study may guide new areas of research, improve clini- AIDS.79–81 Their health systems are mostly uniform in struc- cal practice, inform health policy, and advance the theo- ture, provide a higher complexity of services, and offer retical development of reproductive decision-making. access to good quality services across the population. Evidence of disparities between health systems in higher- and lower-income countries is represented by the differences Objectives in maternal and infant mortality and morbidity rates.82 The purpose of this review was to synthesize the evidence Publication language for the reviewed studies was limited about the reproductive decision-making of Black women to English and Spanish. Age was not limited, but an upper living with HIV in high-income countries from the begin- demarcation of 55 years was set for reproductive age when ning of the HIV epidemic to the present. The principal assessing data that included age groups from later years. objective was to describe the factors that influence repro- ductive decision-making of Black women living with HIV. Key questions guiding this review included the following: Information sources (a) Since the beginning of the HIV epidemic, how has the Multiple electronic databases were searched from January evidence for reproductive decision-making of Black 1985 to August 2021, including CINAHL, Embase, women living with HIV evolved? (b) In studies reporting MEDLINE (through PubMed), Scopus, Social Sciences data for women of different races and ethnicities, how do Citation Index, Cochrane Library, and PsycINFO. The influencing factors compare in subgroup analyses? (c) publication date range was chosen so all studies for the What is the relationship between Black women living with entire HIV epidemic would be included. HIV and their reproductive intentions across cultures and countries? (d) What are the barriers and facilitators for reproductive decision-making? and (e) How has the Search strategy advancement of antiretroviral therapy impacted decisions The keywords for this review were guided by systematic about pregnancy? reviews in related areas and defined by the research team 4 Women’s Health Table 1. Search strategy example. agreement between paired reviewers for the title and abstract phases; the predetermined 95% agreement was CINAHL RESULTS achieved in each round. The 2020 PRISMA flow diagram76 (Decision making OR attitudes OR beliefs OR 213 details the results of the screening process. meaning OR behavior OR behavior) AND (AIDS OR HIV OR seropositive OR serodiscordant) AND (pregnancy OR pregnant OR reproduction OR Data collection reproductive OR family planning OR contraception) NOT (screening or testing) Data extraction for each study focused on the results and Narrow by subject geographic: Mexico & Central / conclusion sections. All figures and tables were reviewed South America, Asia, Middle East, Australia & New for data specific to Black women living with HIV. General Zealand, continental Europe, the United States, the data related to the review objectives were independently United Kingdom and Ireland, Europe extracted line-by-line from the articles by two review Narrow by subject age: middle-aged: 45–64 years, authors (AH-Z and JL-M) and recorded in an Excel spread- adult: 19–44 years sheet with a separate tab for each study. The review authors Narrow by language: English, Spanish Search modes: Boolean/Phrase then organized the data by aim, setting, participants, study Narrow by sex: female design, interview data (direct quotes), numerical data, and Narrow by date from January 01, 2017 to August 30, key findings. Data items of interest were assessments, 2021 measurements, experiences, and characteristics related to reproductive decision-making. after consultation with a reference librarian. Specifically, the keywords were HIV, AIDS, pregnancy, reproduction, Risk of bias assessment and decision-making. In addition to the keywords, Boolean The studies included in the full-text review were indepen- operators were tailored for each database search. The dently reviewed by two review authors (AH-Z and JL-M) search was not limited by race or ethnicity since most stud- using established tools for risk and methodological quality ies were expected to include data on Black women living assessment, specifically the Quality Assessment Tool for with HIV. A hand search for references from documents Observational Cohort and Cross-Sectional Studies85 and such as systematic reviews focused on HIV and women the Critical Appraisal Skills Program for qualitative stud- was also completed during this process. The example ies.86 Any uncertainty or disagreement was discussed by search strategy is provided in Table 1. the same two to achieve consensus followed by an inde- pendent review (PAP) of the decision. Selection process The selection process was divided into two phases. First, Data synthesis records (n = 1602) were identified from a previous system- Once assessment was completed for each study, the data atic review83 about the reproductive decision-making of were organized in an Excel spreadsheet. Although a meta- women living with HIV. Next, new records (n = 2145) analysis of the numerical data extracted from the studies were identified through an updated search of the above was originally planned, this analysis was not possible databases for studies published between January 1, 2017, because the studies lacked homogeneous data and had too and July 31, 2021. All records from the searches were then many variations in observational study designs. Thus, a merged for an initial screening that followed an established qualitative descriptive analysis was instead completed for study selection process84 with three review layers (title, the abstracted data. Results were then synthesized based abstract, and article). All record titles were independently on the research question, and findings were organized into screened by four paired teams of experienced reviewers to defined decision-making influence categories83 for identify the studies that met inclusion criteria. The abstracts women living with HIV but with minor modifications for for the included titles were then reviewed, where each this review. Organizing the findings in this manner high- paired team assessed a different group of abstracts than the lighted the multiple similarities and contrasted the few titles in the previous step. Finally, the paired teams differences. Selective reporting within studies was possi- screened the full text of the remaining reports, strictly ble because of the lack of subgroup analysis for race and applying the inclusion and exclusion criteria. During each ethnicity. round, a third reviewer checked the work of each paired team for discrepancies and errors. If there was disagree- ment between paired reviewers, the report was advanced Ethical considerations to the next phase of the review process to limit deselection For this review, ethics approval was not necessary since bias. The primary investigator checked the level of there were no human participants. All searches were Huertas-Zurriaga et al. 5 Figure 1. PRISMA 2020 flow diagram. Reference: Page et al.87 For more information: http://www.prisma-statement.org/. conducted in publicly accessible databases. However, the from the current review. A full-text screening of 212 studies studies included in the review were evaluated for appropri- was completed, and 190 studies were excluded for various ate ethical standards for research involving human partici- reasons. Of the final studies (n = 22) included in this review, pants, and they all reported approval by an ethics committee most studies (n = 15) reported groups of women living with or institutional review board. HIV and had extractable data relevant to the review criteria; only a few studies (n = 4) focused on Black women. All reviewed studies met the minimum risk and methodologi- Results cal assessment for quality. Results of the screening process After removing duplicate records, 3503 records were iden- are reported as a PRISMA flow diagram in Figure 1. tified through the systematic database searches. The records In terms of the publication years of the included studies, included 1563 studies from a previous review83 and 1940 six were published between 1995 and 2000, six were 6 Women’s Health published between 2001 and 2010, two were published analysis of women living with HIV (n = 490) and found between 2011 and 2015, and the remaining and eight were Black women of African ethnicity (n = 219) were more published after 2015. As summarized in Table 2, most likely to have children and African ethnicity was a signifi- studies (n = 18) were conducted in the United States, and cant predictor (p < 0.0001) of fertility intention in their the remainder were in Canada, France, and the United multivariable model. Finally, a study from the United Kingdom. The studies were predominantly quantitative Kingdom reported no statistically significant differences (n = 19) with observational designs (cross-sectional), but in the effect of HIV diagnosis on fertility intentions by eth- there were a few qualitative (n = 3) designs (descriptive, nicity (p = 0.08) although Black women with African eth- focus group, and phenomenology). Most studies included nicity were slightly more likely to report no change in participants from urban settings who were mostly Black fertility intentions.100 women of African ethnicity. The mean age of the women was 31.6 years. Most studies did not report information Religion and spirituality about education level (n = 8) or route of HIV infection (n = 7). For those studies that did report this information, Religion and spirituality were important concepts for most women had completed high school, and the route of Black women living with HIV who were considering preg- infection was most often a sexual route. nancy.98 Faith not only helped the women cope with every- No major differences were identified by race or ethnic- day stresses related to their HIV-positive status, but also ity from previously reported categories of factors influenc- helped them manage daily living. Black women often ing the reproductive decision-making of women living underscored their ruminations about the risks of vertical with HIV. However, there were minor differences in some transmission with the belief that God would protect their factors across categories related to mental health, religion, baby.98 From their perspective, God had the power to heal and relationships. For this reason, synthesis results were and the power to decide the pregnancy outcome even when organized and reported by previously reported categories. they contemplated an elective abortion. Specifically, the seven categories were ethnicity, race, and pregnancy; religion and spirituality; attitudes and beliefs Attitudes and beliefs about antiretroviral about antiretroviral therapy; supportive people; mother- hood and fulfillment; reproductive planning; and health therapy and wellness. Given the variety of treatment options, women living with HIV can safely attempt pregnancy. In one study,93 under- standing the benefits of zidovudine made women living Ethnicity, race, and pregnancy with HIV more likely to consider pregnancy (n = 192, In earlier research from the United States, race was not p = 0.0001) than those who were not knowledgeable, and related to planning or terminating a pregnancy.91 For no differences were found by ethnicity regarding knowl- example, Kline et al.88 reported 29.2% of Black women edge of zidovudine. Although results were not statistically became pregnant after an HIV-positive diagnosis, which significant, in another study, a lower proportion of non- was similar to the 28.4% of White women who did. London residents, Black women from African countries, Regarding ethnicity, Hispanic women were more likely, at women older than 29 years, and women more recently 42.3%, to become pregnant. In another study,97 statistically diagnosed with HIV (< 5 years) changed their decision to significant predictors regarding the desire for childbearing have children when they learned about improvements in were younger age, not currently on an HIV medication, treatments that safely facilitate pregnancy.100 higher current CD4 cell count, and a relationship duration of less than 2 years; race was not associated with a desire Supportive people for children. Similarly, more recent studies reported the desire to become pregnant was unrelated to ethnicity.101,108 Healthcare providers have a key role in helping women For women living with HIV, being a Black non-Hispanic living with HIV make informed reproductive decisions. woman was not significantly associated with the desire to However, when offered to women, reproductive coun- have children (adjusted odds ratio (AOR) = 0.93, 95% con- seling was reported as being poor and inconsistent across fidence interval (CI) (0.31, 2.78)).108 contexts and countries.110,111 Insufficient information about In other settings, Black women born in Africa but living treatment advancements and reductions in transmission in France were more likely than other groups to desire risks to the fetus resulted in women perceiving even greater children.96 The desire to have children was two to six times stigmatization from healthcare providers.102 Furthermore, higher among women born in sub-Saharan (odds ratio HIV status was the most important influencing factor for (OR) = 2.38, 95% CI (1.28, 4.43)) and North Africa (OR Black women engaged in reproductive decision-making. 5.73, 95% CI (1.74, 18.85)) than among women born in Black women also named significant others (husbands and Europe.96 Similarly, Loutfy et al.99 performed a univariate partners) and other family members as the most important Table 2. Summary of study findings in chronological order. Author(s) Location (context) Method (design) Aims/purpose Key findings 88 Kline et al. United States Observational Describe the profiles of women living with HIV becoming Black women with pregnancy since HIV diagnosis (29.2%) was similar to White women (28.4%) but less than (urban) (cross-sectional) pregnant; understand the reasons for becoming pregnant; and Hispanic women (42.3%). Associations between independent variables and women continuing pregnancy to Huertas-Zurriaga et al. examine pregnancy outcomes term: Black (50.4%), White (37.9%), and Hispanic (41.6%). Few differences were statistically significant due to small sample size; but descriptively informative Bedimo et al.89 United States Qualitative Explore the barriers to condom use among Black women living Pregnancy gave women a societal status that entitled them to things they would not otherwise receive; (urban) (focus groups) with HIV pregnancy with HIV was a double burden, including concerns about their health, and possibility of having an infected baby Bedimo et al.90 United States Observational Describe the characteristics of HIV positive women who Abortion among women pregnant after learning their HIV diagnosis was significantly associated with being (urban) (cross-sectional) became pregnant, chose sterilization, and elected abortion White and non-single. Race was not associated with pregnancy after adjusting for age and sexual assault after diagnosis history Smits et al.91 United States Observational Understand the relationship between knowledge of HIV Race was not significantly related to subsequent pregnancy planning or termination (women without (urban) (cross-sectional) infection and prenatal benefits of AZT, decisions about intravenous drug use living with HIV). Neither any contraceptive nor consistent contraceptive use was pregnancy planning, contraceptive use, and abortion significantly associated with race Sowell et al.92 United States Observational Identify the perception of Black women living with HIV about HIV status is not the most important influence for the reproductive decision-making of a Black woman; (urban) (cross-sectional) the risk for perinatal transmission; and examine the factors they identified significant others (husbands and sex partners) and family members as those more important that influence their pregnancy decision influences for making the decision to have a child Vitiello and United States Observational Assess the knowledge of women living with HIV about There were no relationships on chi-squared analysis between knowledge about AZT to reduce prenatal Smeltzer93 (urban) (cross-sectional) AZT use to reduce transmission during pregnancy and to transmission during pregnancy by age or by ethnicity. Women living with HIV understanding the benefits understand their reproductive perspective of zidovudine were more likely to consider pregnancy (n = 192; p = 0.0001) than those not knowledgeable, without differences in knowledge by ethnicity Chen et al.94 United States Observational Understand fertility and attitudes about contraception and All women living with HIV who desired children, 47% were Black; of the Black women 36% expected no (n/a) (cross-sectional) behaviors of HIV positive men and women children and 52% expected more than one child Bedimo-Rung United States Observational Describe factors related to reproductive decision-making Since HIV diagnosis, Black women with pregnancy 23.17% (n = 38); without pregnancy 26.83% (n = 44); et al.95 (urban) (case–control) before the use of HAART among African Americans living with surgical sterilization 21.34% (n = 35); and without sterilization 28.65% (n = 47) HIV Heard et al.96 France Observational Describe the sociodemographic and health-related factors Status variables indicated being born in Africa was associated with the desire to have children. The desire (n/a) (cross-sectional) influencing the desire to have a child among heterosexual to have children was two to six times higher among women born in sub-Saharan (OR 2.38, 95% CI (1.28, individuals of reproductive age living with HIV 4.43)) and North Africa than Europe (OR 5.73, 95% CI (1.74–18.85)) Stanwood et al.97 United States Observational Examine the determinants of contraceptive use, desire for Multivariate analysis, statistically significant predictors of desire for future childbearing were younger age, (urban) (cross-sectional) children, and sterilization regret among women living with HIV not being on HIV medication, higher current CD4 cell count, and relationship duration < 2 years. No association with race Polzer et al.98 United States (n/a) Qualitative Describe how spirituality impacts African American mothers Perceived as a benevolent authority, God controls all aspects of their lives; power to heal; protects their (descriptive) living with HIV in the context of coping baby from infection; and encourages them to avoid abortion Loutfy et al.99 Canada Observational Assess fertility desires, intentions, and actions of reproductive Women living with HIV intending to have children were more statistically likely to be African ethnicity, in (urban) (cross-sectional) aged women living with HIV in Toronto, Canada univariate analysis. HIV-positive women in 20s or 30s, African descent, living in Toronto, and already given birth, would be most likely to intend to become pregnant Cliffe et al.100 United Kingdom Observational Explore fertility intentions among women living with HIV, There were no statistically significant differences in the effect of HIV diagnosis on fertility intentions by (urban) (cross-sectional) and to assess the effect of treatment and interventions for ethnicity (p = 0.08). Black African women were slightly more likely to report no change in fertility intentions, perinatal transmission on these intentions but 35% did not want children after HIV diagnosis. A lower proportion of non-London residents, Black African women, women over 29 years old, and those diagnosed for < 5 years changed their mind about not wanting children after learning the impact of improvements in treatment and interventions (not statistically significant) (continued) 7 8 Table 2. (Continued) Author(s) Location (context) Method (design) Aims/purpose Key findings Finger et al.101 United States Observational Determine in a population of young women with behaviorally In young women with behaviorally acquired HIV infections (n = 130), 31.5% reported a desire for pregnancy (urban) (cross-sectional) acquired HIV, the association between desire for pregnancy, in the next 6 months; desire for pregnancy was unrelated to ethnicity sociodemographic variables, and sexual risk behaviors Fletcher et al.102 United States Qualitative Explore perspectives of reproduction and motherhood in Pregnancy fostered the sense of normalcy; motherhood was perceived to be transformative, inspirational, (n/a) (phenomenology) African American women living with HIV of childbearing and purpose-filled; or a second chance. The advice of health care providers was either supportive or non- capacity; and the advice received from health care providers supportive Raziano et al.103 United States Observational Identify the factors associated with sterilization among women Women living with HIV (n = 187), 88% Black or African American, with 41 women sterilized from which 33 (urban) (cross-sectional) living with HIV were Black and eight White women. All other women (n = 146) used intrauterine device, implant, injection, pill, patch, ring, condom, withdrawal, and none. Differences in sterilization by ethnicity were not significant (p = 0.8) Kaida et al.104 Canada (urban) Observational Measure the prevalence and correlates of effective Women living with HIV (n = 453), with 141 (31%) African American; Black women, 66.7% (n = 94), in the (cross-sectional) contraceptive use among sexually active women living with HIV past 6 months used contraceptives, and 33.3% did not (n = 47). Overall, 73% of women in the prior 6 months in Canada, and to assess the range of methods used, as well as used contraceptives. Greater proportions of women who had not used contraceptives than used them method satisfaction and reasons for nonuse were African, Caribbean, or Black (39% vs. 29%); no association between Black race and contraceptive use (OR = 0.54, 95% CI (0.29, 1.03), AOR = 0.56, 95% CI (0.27, 1.15). Polansky et al.105 United States Observational Determine whether pregnancy happiness was positively Black women living with HIV had higher mean prenatal depressive symptoms (M = 19.55, SD = 13.53) than all (urban) (cross-sectional) associated with pregnancy planning and wantedness, controlling other women (M = 15.06, SD = 13.24) that was not statistically significant for sociodemographic factors and HIV status Haddad et al.106 United States Observational Explore the reproductive health knowledge, attitudes, and Women living with HIV (n = 103) with 92 (89.3%) Black from which 27 (29.3%) not sexually active, 26 (urban) (cross-sectional) practices among adolescents and young adults living with HIV (28.3%), used condoms, 16 (17.4%) used dual method, 13 (14.1%) used hormonal or intrauterine device, and receiving medical care at an HIV clinic in Atlanta 10 (10.9%) did not use a method at last coitus. Race not associated with increased odds of contraceptive use at last coitus Tote et al.107 United States Observational Evaluate factors associated with women living with HIV Women living with HIV (n = 136) with 123 (90.6%) Black or African American. From all participants, 42 (urban) (cross-sectional) method of contraceptive at last coitus defined as more used T1/T2 from which 41 (97.6%) were Black, and 94 used T3/none, from which 82 (87.23%) were Black. effective (Tier 1 and 2 methods (T1/T2)) versus less effective Differences in race and ethnicity by contraception method used were not significant (p = 0.6) (Tier 3 or no method (T3/none)). Cohn et al.108 United States Observational Describe parenting desires among women, men who have sex In univariate analysis, factors significantly associated with parenting desires included being Black (this (urban) (cross-sectional) with men, and men who have sex with women group included all participants) (OR = 2.04, 95% CI (1.60, 2.62)). For women living with HIV, being Black non-Hispanic was not significantly associated with parenting desires with (OR = 0.83, 95% CI (0.40, 1.73)). In multivariable analysis of all participants, Blacks had increased odds for considering children in the future (AOR = 2.20, 95% CI (1.45, 3.34)). For women living with HIV, being Black was not significantly associated with parenting desires (AOR = 0.93, 95% CI (0.31, 2.78)) Gursahaney United States Observational Evaluate factors associated with self-reported condom use in Women living with HIV (n = 187). For Black women living with HIV, 108 (73%) used condoms in last coitus. et al.109 (urban) (cross-sectional) a cohort of adult, predominantly African American women During vaginal intercourse over the past 6 months, 82 (55%) used condoms. Race was not significantly receiving HIV care in Atlanta associated with condom use OR: unadjusted odds ratio; AOR: adjusted odds ratio; IC: confidence interval. Women’s Health Huertas-Zurriaga et al. 9 people for consultation and guidance when making the 0.56, 95% CI (0.27, 1.15)).104 Haddad et al.106 found race decision to have a child.112 The findings underscore the was not associated with increased odds of contraceptive importance of family in childbearing decisions for Black use during the last vaginal intercourse. Although not statis- women living with HIV.92 tically significant, two other studies reported differences between ethnicity and contraceptive method (p = 0.06)107 and sterilization status (p = 0.08).103 Motherhood and fulfillment Motherhood was reported to be a vital role that gave mean- Health and wellness ing to the lives of women living with HIV. The recognition of this role may have influenced some Black women living When considering a successful pregnancy, Black women with HIV to try to become pregnant or, at the very least, to living with HIV feared the possibility of mother-to-child not try too hard to prevent it.90 Motherhood was viewed as transmission because they would need to care for an transformative, inspirational, and purposeful. Some Black infected baby.90 Some women believed totally avoiding women actively sought a second chance to responsibly pregnancy was the only way to prevent mother-to-child care for children. Motherhood post-HIV diagnosis repre- transmission.102 For women living with HIV who became sented and reinforced life, hope, purpose, and normalcy. pregnant, Black women reported higher prenatal depres- By extension, pregnancy was an opportunity for “a whole sive symptoms than other women (M= 19.55, SD = 13.53 new second chance at life.”102 vs M= 15.06, SD = 13.24, p < 0.24).105 Such symptoms may influence future reproductive decisions. Reproductive planning Discussion Black women living with HIV used different birth control strategies to plan their pregnancy. During the late 1990s, This review synthesized the evidence about the reproduc- abortion among women who became pregnant after their tive decision-making of Black women living with HIV in HIV diagnosis was significantly associated with being high-income countries from the beginning of the HIV epi- White and in a relationship.113 In earlier studies, race was demic to the present. The categories previously identified not associated with pregnancy after adjusting for age and as factors that influence the reproductive decision-making sexual assault history.90 Smits et al.91 reported that not process for all women living with HIV83 were remarkably using or not consistently using contraceptives was signifi- similar to those identified for Black women. However, cantly associated with race. In a later study,103 elective few studies in this review specifically focused on Black sterilization was a common method to prevent pregnancies women living with HIV, and most did not provide sub- among women living with HIV. Another study reported group analyses by race or ethnicity. Furthermore, the stud- 21% (n = 35) of Black women living with HIV had surgical ies reported limited demographic characteristics of sterilization after learning about their HIV-positive status; participants that could be synthesized by race or ethnicity. 29% (n = 47) were not sterilized.95 Finally, involuntary57 Because of this limited data for analysis, synthesis for and nonconsensual56 sterilizations are common among intersectionality was not possible. However, three key women living with HIV, but more problematic for racial areas related to the findings—reproductive intention, and ethnic minorities.57 mental health, and research inequity—have implications Women living with HIV effectively used contraceptives for policy, practice, and future research. to prevent unwanted pregnancies. In one study with open- ended responses, 73% of women living with HIV used Reproductive intention contraceptives in the 6 months before the study.104 Condoms were the most popular contraceptive for Black Although HIV status seems to have little impact on a wom- women living with HIV, and more than 70% of them used an’s decision to have children, cultural, and contextual fac- a condom during their last vaginal intercourse. However, tors make the decision-making process more complex.114 race has not been reported as significantly associated with Regardless of race and ethnicity, motherhood after an HIV condom use.109 A more recent study found 28% of Black diagnosis offers women living with HIV an opportunity women living with HIV used only condoms, 17% used for normalcy, achieved through a second chance at life dual methods, 14% used only hormonal contraception, and with a family.115 In this review, no relationship was found 11% did not use any method during their last vaginal inter- between race or ethnicity and planning or ending a preg- course.106 Women who chose to not use contraception nancy in the United States, but some studies from Europe were significantly more likely to be Black (mostly African reported Black women with African ethnicity were less and Caribbean) than another race (39% vs 29%). However, likely to change their fertility intentions after an HIV diag- there was no association between effective contraceptive nosis than European women. This finding may be related use and Black women (OR 0.54, 95% CI (0.29, 1.03); OR to the positive association between African cultural values 10 Women’s Health and the importance of having children for Black women research focuses on White women.83 Studies that that was reported in an older study.116 In a retrospective included Black women rarely reported subgroup analy- review of women living with HIV in Canada (n = 1165), sis for race or ethnicity. One notable exception is a sec- 30% of the women identified as African/Caribbean/Black, ondary data analysis112 published nearly 20 years almost 25% became pregnant after their HIV diagnosis following the original data collection.131 that examined with slightly more than 60% unintended.117 However, none the major influencers of Black mothers with HIV. As a of the reported data was specific to race and ethnicity. result, the scientific literature has largely ignored Black Black women living with HIV usually want to continue women living with HIV despite their increased risk for their pregnancy,118 but they also need to feel their baby is adverse health outcomes,132 problems with stigma and protected from HIV.119,120 For this reason, some Black discrimination,129 and barriers to accessing health ser- women turn to their faith in God and pray for a good out- vices. Targeted funding is essential to increase the level come.119 However, involuntary57 and nonconsensual56 of research and tailor clinical programs to address repro- sterilizations are reported to eliminate reproductive deci- ductive health. As a community, Black women living sion-making for women living with HIV especially in the with HIV need to be prioritized as key stakeholders133 in case of racial and ethnic minorities.57 More research is the development of new approaches that increase their needed to understand the reproductive intentions of Black access to women-centered care.18 women living with HIV and to support their reproductive decision-making and family planning in relation to their culture and context. Limitations This review had several limitations. Few studies reported data that could be extracted for synthesis specific to race Mental health or ethnicity. However, to our knowledge, this is the first In this review, significantly higher mean prenatal depres- systematic review focused on the reproductive decision- sive symptoms were reported for Black women living making of Black women living with HIV. Although most with HIV than for other women.105 Similarly, a system- studies were conducted in urban areas of the United atic review of depression in HIV-infected African women States, there were similarities with the few studies con- reported a 23% mean weighted prevalence for antenatal ducted in other countries. The lack of sociodemographic (13 studies) and postnatal depression (10 studies); sus- participant data and subgroup analysis for race and eth- pected depression was reported to be 43% and 31%, nicity from the reviewed studies limited the depth of respectively.121 Because symptoms in the studies were analysis and prevented a robust review of intersectional- not explained by timing or etiology, depression may ity. Despite these limitations, major strengths of this have been an underlying condition during the reproduc- review were the depth and breadth of the literature tive decision-making process.122 Depressive symptoms search, the longevity of the literature reviewed, the rig- for Black women are often missed or not clinically man- orous methods, and the quality assessment. Finally, the aged by providers.123 For example, Black women are including criteria for OECD member countries can be less likely to receive treatment for mental health prob- considered a weakness as the literature specific to Black lems than nearly all other racial and ethnic groups.124 In women of African ethnicity from other countries was not the United States, White women are twice as likely to included in this review. However, the inclusion criteria receive treatment for depression related to pregnancy can also be considered a strength as the OECD countries than Black women.125 Furthermore, most mental health are more comparable in the socioeconomic and human research specific to pregnancy and to development of rights conditions for women. This limitation is an impor- screening tools has focused on White women. More tant area for further research focused on the other research is needed to understand mental health in all countries. groups of women living with HIV,126 most especially for depression experienced by Black women127 engaging in Conclusion reproductive decision-making. Becoming a mother can be a transformative, inspirational, and purposeful experience for all groups of women. In Research inequity this review, there were few differences in the reproductive For women living with HIV accessing health services decision-making process between Black women and other worldwide, inadequate resources and lack of evidence- groups of women living with HIV. However, the desire to based clinical guidelines result in poor health out- have children was more pronounced for Black women comes128 and high levels of marginalization.129 Although from Africa living with HIV in Europe. Also, prenatal Black women are disproportionately impacted by an depressive symptoms were more often observed among HIV diagnosis,44,130 most reproductive decision-making Black women. Furthermore, religion and spirituality Huertas-Zurriaga et al. 11 helped Black women cope with their HIV infection and Funding manage fears about vertical transmission. Unfortunately, The author(s) disclosed receipt of the following financial support dehumanizing behaviors and stigmatizing practices still for the research, authorship, and/or publication of this article: exist in healthcare institutions. The dissemination of this study was funded by the Dirección de Of the 35 OECD countries, studies from only four Desarrollo de la Investigación, Universidad Norbert Wiener countries investigated the reproductive decision-making (Grant number: VRI-D-2021-06-002-RDG). The funding agency of Black women living with HIV. Despite the dispropor- had no role in study design, data collection, data analysis, data tionately larger number of Black women living with HIV, interpretation, or writing of the manuscript. All authors had full very few studies reported subgroup analysis for race or access to the data for the study. The primary, corresponding, and last authors had the final responsibility for the decision to submit ethnicity. Therefore, institutional review boards should the manuscript for publication. require subgroup analysis for Black women in larger stud- ies of women living with HIV. Furthermore, clinical trials specifically focused on Black women are necessary to bet- ORCID iDs ter understand the biopsychosocial factors associated with Patrick A Palmieri https://orcid.org/0000-0002-0765-0239 reproductive decision-making. As such, funding agencies Mariela P Aguayo-Gonzalez https://orcid.org/0000-0002- should take a proactive role in promoting research that 5968-5214 investigates Black women living with HIV. Karen A Dominguez-Cancino https://orcid.org/0000-0002- 4264-8476 Acknowledgements Cristina Casanovas-Cuellar https://orcid.org/0000-0003- The authors appreciate the continued guidance and support pro- 2077-1542 vided by the Joanna Briggs Institute (University of Adelaide) and Sandra K Cesario https://orcid.org/0000-0002-2804-0878 the Evidence-Based Health Care South America: A JBI Affiliated Juan M Leyva-Moral https://orcid.org/0000-0003-4241- Group. The authors also recongize thank Deborah Goggin, MA, 4992 ELS, scientific writer from the Department of Research Support at A.T. Still University, for her excellent editorial review. Finally, the authors are truly grateful to all the Black women living with Supplemental material HIV who took the time to share their experiences and to complete the surveys for the research studies included in this review. Supplemental material for this article is available online. Author contribution(s) References Ariadna Huertas-Zurriaga: Conceptualization; Data curation;   1. Tubert S. Los ideales culturales de la feminidad y sus efec- Formal analysis; Investigation; Methodology; Project adminis- tos sobre el cuerpo de las mujeres. Quaderns Psicol 2010; tration; Writing – original draft; Writing – review & editing. 12: 161–174. Patrick A Palmieri: Conceptualization; Data curation; Formal   2. Leyva-Moral JM. La dominación del cuerpo femenino: analysis; Funding acquisition; Investigation; Methodology; análisis feminista del climaterio y las prácticas de cuidado Supervision; Writing – original draft; Writing – review & profesional. Ene 2014; 8, https://scielo.isciii.es/scielo. editing. php?script=sci_arttext&pid=S1988-348X2014000100005 Mariela P Aguayo-Gonzalez: Data curation; Formal analysis;   3. Morison T. Heterosexual men and parenthood decision Writing – original draft. making in South Africa: attending to the invisible norm. J Karen A Dominguez-Cancino: Data curation; Formal analysis; Family Iss 2013; 34: 1125–1144. Writing – review & editing.   4. Rijken A and Knijn T. Couples’ decisions on having a first Cristina Casanovas-Cuellar: Data curation; Formal analysis; child: comparing pathways to early and late parenthood. Writing – review & editing. Demograph Res 2009; 21: 765–802. Kara L Vander Linden: Data curation; Formal analysis;   5. Meyers DT. The rush to motherhood: pronatalist discourse Writing – review & editing. and women’s autonomy. Signs 2001; 26: 735–773. Sandra K Cesario: Data curation; Formal analysis; Writing –   6. Krause EL. “They just happened”: the curious case of review & editing. the unplanned baby, Italian low fertility, and the “end” of Joan E Edwards: Data curation; Formal analysis; Writing – rationality. Med Anthropol Q 2012; 26(3): 361–382. review & editing.   7. Hadley RA. “I’m missing out and I think I have something Juan M Leyva-Moral: Conceptualization; Data curation; to give”: experiences of older involuntarily childless men. Formal analysis; Investigation; Methodology; Supervision; Work Older People 2018; 22: 83–92. Writing – original draft; Writing – review & editing.   8. Riggs DW and Bartholomaeus C. “It’s just what you do”: Australian middle-class heterosexual couples negotiating compulsory parenthood. Femin Psychol 2018; 28: 373– Declaration of conflicting interests 389. The author(s) declared no potential conflicts of interest with   9. Riggs DW and Bartholomaeus C. The desire for a child respect to the research, authorship, and/or publication of this among a sample of heterosexual Australian couples. J article. Reprod Infant Psychol 2016; 34: 442–450. 12 Women’s Health   10. Overall C. Why have children? The ethical debate.   28. Kelly C, Lohan M, Alderdice F, et al. Negotiation of risk Cambridge, MA: The MIT Press, 2013. in sexual relationships and reproductive decision-making   11. Liamputtong P. Women, motherhood and living with HIV/ amongst HIV sero-different couples. Cult Health Sex AIDS: A cross-cultural perspective. Cham: Springer, 2011; 13(7): 815–827. 2013.   29. Kirshenbaum SB, Hirky AE, Correale J, et al. “Throwing   12. Corrêa S, McIntyre P, Rodrigues C, et al. The population the dice”: pregnancy decision-making among HIV- and reproductive health programme in Brazil 1990-2002: positive women in four U.S. Perspect Sex Reprod lessons learned. Reprod Health Matt 2005; 13(25): 72–80. Health 2004; 36(3): 106–113.   13. Haberl A and Reitter A. How does HIV affect the repro-   30. Park J, Nordstrom SK, Weber KM, et al. Reproductive ductive choices of women of childbearing age. Antivir coercion: uncloaking an imbalance of social power. Am J Ther 2013; 18(Suppl 2): 35–44. Obstet Gynecol 2016; 214(1): 74–78.   14. Mazzeo CI, Flanagan EH, Bobrow EA, et al. How the   31. Cuca YP and Rose CD. Social stigma and childbearing global call for elimination of pediatric HIV can support for women living with HIV/AIDS. Qual Health Res 2016; HIV-positive women to achieve their pregnancy inten- 26(11): 1508–1518. tions. Reprod Health Matters 2012; 20(39 Suppl): 90–102.   32. van Dijk MG, Wilson KS, Silva M, et al. Health care   15. Saleem HT, Narasimhan M, Denison JA, et al. Achieving experiences of HIV-infected women with fertility desires pregnancy safely for HIV-serodiscordant couples: a social in Mexico: a qualitative study. J Assoc Nurses AIDS Care ecological approach. J Int AIDS Soc 2017; 20: 21331. 2014; 25(3): 224–232.   16. Campero L, Kendall T, Caballero M, et al. El ejercicio de   33. Kumar S, Gruskin S, Khosla R, et al. Human rights los derechos sexuales y reproductivos: Un estudio cuali- and the sexual and reproductive health of women liv- tativo de personas heterosexuales con VIH en México. ing with HIV—a literature review. J Int AIDS Soc 2015; Salud Pública de México 2010; 52: 61–69. 18(Suppl5): 20290.   17. Fransen-dos Santos R and Guarinieri M. Men living with   34. Gruskin S, Ferguson L and O'Malley J. Ensuring sexual HIV in serodiscordant relationships who desire a child/ and reproductive health for people living with HIV: an children. J Int AIDS Soc 2017; 20: 21749. overview of key human rights, policy and health systems   18. O'Brien N, Greene S, Carter A, et al. Envisioning women- issues. Reprod Health Matters 2007; 15(29 Suppl): 4–26. centered HIV care: perspectives from women living with   35. O’Neill D. Abortion as a moral good? Lancet 2019; 394: HIV in Canada. Womens Health Iss 2017; 27(6): 721–730. 1323–1324.   19. Leyva-Moral JM, Piscoya-Angeles PN, Edwards JE, et al.   36. Watson K. Abortion as a moral good. Lancet 2019; 393: The experience of pregnancy in women living with HIV: 1196–1197. a meta-synthesis of qualitative evidence. J Assoc Nurses   37. Loutfy M, Tharao W, Kazemi M, et al. Development of AIDS Care 2017; 28(4): 587–602 the Canadian women-centred HIV care model using the   20. Joint United Nations Programme on HIV/AIDS. The gap knowledge-to-action framework. J Int Assoc Provid AIDS report. Geneva: UNAIDS, 2014. Care 2021; 20: 1–15.   21. Brown JL, Haddad LB, Gause NK, et al. Examining the   38. Medeiros P, Gupta M, Wong H, et al. Women-centred contraceptive decisions of young, HIV-infected women: a HIV care: a scoping review to understand the current state qualitative study. Women Health 2019; 59(3): 305–317. of service delivery for women living with HIV globally.   22. Mandelbrot L, Tubiana R, Le Chenadec J, et al. No peri- AIDS Care 2021. DOI: 10.1080/09540121.2021.1948498. natal HIV-1 transmission from women with effective   39. Chambers LA, Rueda S, Baker DN, et al. Stigma, HIV and antiretroviral therapy starting before conception. Clin Inf health: a qualitative synthesis. BMC Public Health 2015; Dis 2015; 61: 1715–1725. 15: 848.   23. American College of Obstertics Gynecology . Committee   40. Geter A, Herron AR and Sutton MY. HIV-Related stigma opinion 751: labor and delivery management of women by healthcare providers in the United States: a systematic with human immunodeficiency virus infection. Obstetr review. AIDS Patient Care STDS 2018; 32(10): 418–424. Gynecol 2018; 132: e131–e137.   41. Paudel V and Baral KP. Women living with HIV/AIDS   24. Leyva-Moral JM, Aguayo-Gonzalez M, Palmieri PA, (WLHA), battling stigma, discrimination and denial and et al. Attitudes and beliefs of nurses and physicians the role of support groups as a coping strategy: a review of about managing sexual health in primary care: a multi- literature. Reproductive Health 2015; 12: 53. site cross-sectional comparative study. Nurs Open 2021;   42. Huertas-Zurriaga A, Palmieri PA, Edwards JE, et al. 8(1): 404–414. Motherhood and decision-making among women living   25. Barnes DB and Murphy S. Reproductive decisions for with HIV in developed countries: a systematic review with women with HIV: motherhood’s role in envisioning a qualitative research synthesis. Reproductive Health 2021; future. Qual Health Res 2009; 19(4): 481–491. 18: 148.   26. Carlsson-Lalloo E, Rusner M, Mellgren A, et al. Sexuality   43. Pellowski JA, Kalichman SC, Matthews KA, et al. A pan- and reproduction in HIV-positive women: a meta-synthe- demic of the poor: social disadvantage and the U.S. Am sis. AIDS Patient Care STDS 2016; 30(2): 56–69. Psychol 2013; 68(4): 197–209.   27. Jean J, Coll A, Monda M, et al. Perspectives on safer con-   44. Martin EG, Ansari B, Hart-Malloy R, et al. Racial and ception practices and preconception counseling among ethnic disparities in HIV diagnoses among heterosexually women living with HIV. Health Care Women Int 2016; active persons in the United States nationally and by state, 37(10): 1096–1118. 2018. PLoS ONE 2021; 16(9): e0257583. Huertas-Zurriaga et al. 13   45. Bradley ELP, Williams AM, Green S, et al. Disparities   65. Algarin AB, Zhou Z, Cook CL, et al. Age, sex, race, incidence of human immunodeficiency virus infection ethnicity, sexual orientation: intersectionality of margin- among black and whitewomen—United States, 2010- alized-group identities and enacted HIV-related stigma 2016. Morbid Mortal Wkly Rep 2019; 68: 416–418. among people living with HIV in Florida. AIDS Behav   46. Centers for Disease Control Prevention. HIV surveillance 2019; 23(11): 2992–3001. report, 2019, https://www.cdc.gov/hiv/library/reports/hiv-   66. Nyashanu M and Serrant L. Engaging black sub-Saharan surveillance.html African communities and their gatekeepers in HIV preven-   47. Brown A, Rawson S, Kelly C, et al. Women and HIV in the tion programs: challenges and strategies from England. United Kingdom: Data to end of December 2017. London: Family Med Commun Health 2016; 4: 22–29. Public Health England, 2019.   67. Greaves L. Women, gender, and health research. In:   48. Prather C, Fuller TR, Marshall KJ, et al. The impact of Armstrong P and Pederson A (eds) Women’s health: racism on the sexual and reproductive health of African Intersections of policy research and practice. 2nd ed. American women. J Womens Health (Larchmt) 2016; Toronto, ON, Canada: Women’s Press, 2015, pp .9–30. 25(7): 664–671.   68. Serrant-Green L. The sound of ‘silence’: a framework for   49. Sengupta S, Banks B, Jonas D, et al. HIV interventions researching sensitive issues or marginalised perspectives to reduce HIV/AIDS stigma: a systematic review. AIDS in health. J Res Nurs 2011; 16: 347–360. Behav 2011; 15(6): 1075–1087.   69. Viruell-Fuentes EA, Miranda PY and Abdulrahim S.   50. Brownley JR, Fallot RD, Wolfson Berley R, et al. Trauma More than culture: structural racism, intersectionality history in African-American women living with HIV: theory, and immigrant health. Soc Sci Med 2012; 75(12): effects on psychiatric symptom severity and religious cop- 2099–2106. ing. AIDS Care 2015; 27(8): 964–971.   70. Prather C, Fuller TR, Jeffries WL 4th, et al. Racism,   51. Brucker MC. Social determinants of health. Nurs Women’s African American women, and their sexual and reproduc- Health 2017; 21: 7–8. tive health: a review of historical and contemporary evi-   52. Riley AR. Advancing the study of health inequality: dence and implications for health equity. Health Eq 2018; fundamental causes as systems of exposure. SSM Popul 2(1): 249–259. Health 2020; 10: 100555.   71. Skerritt L, Kaida A, O’Brien N, et al. Patterns of changing   53. Earnshaw VA, Bogart LM, Dovidio JF, et al. Stigma and pregnancy intentions among women living with HIV in racial/ethnic HIV disparities: moving toward resilience. Canada. BMC Women’s Health 2021; 21: 350. Am Psychol 2013; 68(4): 225–236.   72. Tariq S, Elford J, Cortina-Borja M, et al. The association   54. Crenshaw KW. On intersectionality: Essential writings. between ethnicity and late presentation to antenatal care New York: The New York Press, 2017. among pregnant women living with HIV in the UK and   55. Hill Collins P. Intersectionality as critical social theory. Ireland. AIDS Care 2012; 24(8): 978–985. Durham, NC: Duke University Press, 2019.   73. Fletcher FE, Amutah-Onukagha N, Attys J, et al. How can   56. Rowlands S and Amy JJ. Non-consensual sterilization the experiences of black women living with HIV inform of women living with HIV. Int J STD AIDS 2018; 29(9): equitable and respectful reproductive health care delivery? 917–924. AMA J Ethics 2021; 23: E156–E165.   57. Sifris R. Involuntary sterilization of HIV-positive women:   74. Aromataris E and Munn Z. JBI manual for evidence syn- an example of intersectional discrimination. Hum Rights thesis. Adelaide, SA, Australia: Joanna Briggs Institute, Quart 2015; 37: 464–491. 2020.   58. Rosenthal L and Lobel M. Gendered racism and the sexual   75. Moher D, Liberati A, Tetzlaff J, et al. Preferred report- and reproductive health of Black and Latina Women. Ethn ing items for systematic reviews and meta-analyses: the Health 2020; 25(3): 367–392. PRISMA statement. PLoS Med 2009; 6: e1000097.   59. Serrant L. Silenced knowing: an intersectional framework   76. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA for exploring Black women’s health and diasporic identi- 2020 statement: an updated guideline for reporting sys- ties. Front Sociol 2020; 5: 1. tematic reviews. PLoS Med 2021; 18: e1003583.   60. Crenshaw K. Mapping the margins: intersectionality,   77. Huertas-Zurriaga A, Palmieri PA, Casanovas C, et al. identity politics, and violence against women of color. Reproductive decision making in black women living with Stanf Law Rev 1991; 43: 1241–1299. HIV. Int J Nurs Stud 2018; 77: 207–221.   61. McCall L. The complexity of intersectionality. Signs   78. Organization for Economic Co-operation Development. 2005; 30: 1771–1800. Secretary general’s report to ministers. Paris: OECD   62. Crenshaw KW. Demarginalizing the intersection of race Publishing, 2018. and sex: a Black feminist critique of antidiscrimination   79. Hickey MD, Odeny TA, Petersen M, et al. Specification doctrine, feminist theory and antiracist politics. University of implementation interventions to address the cascade of of Chicago Legal Forum 1989; 1989: 1. HIV care and treatment in resource-limited settings: a sys-   63. Leath S, Wright P, Charity-Parker B, et al. Exploring tematic review. Implement Sci 2017; 12: 102. Black women’s pathways to motherhood within a repro-   80. Mepham S, Bland R and Newell ML. Prevention of ductive justice framework. Qual Health Res 2022; 32: mother-to-child transmission of HIV in resource-rich and 694–709. -poor settings. BJOG 2011; 118(2): 202–218.   64. Collins PH. Black feminist thought: Knowledge, con-   81. Tudor Car L, van Velthoven M, Brusamento S, et al. sciousness, and the politics of empowerment. New York: Integrating prevention of mother-to-child HIV transmis- Routledge, 1990. sion (PMTCT) programmes with other health services for 14 Women’s Health preventing HIV infection and improving HIV outcomes in   99. Loutfy MR, Hart TA, Mohammed SS, et al. Fertility developing countries. Cochrane Database Syst Rev 2011; desires and intentions of HIV-positive women of repro- 6: CD008741. ductive age in Ontario, Canada: a cross-sectional study.   82. Ramakrishnan R, Rao S and He JR, Perinatal health pre- PLoS ONE 2009; 4: e7925. dictors using artificial intelligence: a review. Womens 100. Cliffe S, Townsend CL, Cortina-Borja M, et al. Fertility Health (Lond) 2021; 17: 1–7. intentions of HIV-infected women in the United Kingdom.   83. Leyva-Moral JM, Palmieri PA, Feijoo-Cid M, et al. AIDS Care 2011; 23(9): 1093–1101. Reproductive decision-making in women living with 101. Finger JL, Clum GA, Trent ME, et al. Desire for preg- human immunodeficiency virus: a systematic review. Int J nancy and risk behavior in young HIV-positive women. Nurs Stud 2018; 77: 207–221. AIDS Pat Care STDS 2012; 26(3): 173–180.   84. Porritt K, Gomersall J and Lockwood C. JBI’s systematic 102. Fletcher FE, Ingram LA, Kerr J, et al. “Out of all of this reviews: study selection and critical appraisal. Am J Nurs mess, I got a blessing”: perceptions and experiences 2014; 114(6): 47–52. of reproduction and motherhood in African American   85. National Heart Lung Blood Institute. Quality assessment tool women living with HIV. J Assoc Nurses AIDS Care 2016; for observational cohort and cross-sectional studies, 2014, 27(4): 381–391. https://www.nhlbi.nih.gov/health-topics/study-quality- 103. Raziano VT, Smoots AN, Haddad LB, et al. Factors asso- assessment-tools ciated with sterilization among HIV-positive US women   86. Critical Appraisals Skills Programme. CASP qualitative in an urban outpatient clinic. AIDS Care 2017; 29(5): studies checklist, 2018, https://casp-uk.net/casp-tools- 612–617. checklists/ 104. Kaida A, Patterson S, Carter A, et al. Contraceptive choice   87. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA and use of dual protection among women living with HIV 2020 statement: an updated guideline for reporting sys- in Canada: priorities for integrated care. Perspect Sex tematic reviews. BMJ 2021; 372: n71. Reprod Health 2017; 49(4): 223–236.   88. Kline A, Strickler J and Kempf J. Factors associated with 105. Polansky M, Singh H, Gao Y, et al. Pregnancy planning, pregnancy and pregnancy resolution in HIV seropositive timing, happiness and depressive symptoms among low- women. Soc Sci Med 1995; 40(11): 1539–1547. income women living with and without HIV. J Reprod   89. Bedimo AL, Bennett M, Kissinger P, et al. Understanding Infant Psychol 2018; 36(3): 222–234. barriers to condom usage among HIV-infected African 106. Haddad LB, Brown JL, King C, et al. Contraceptive, con- American women. J Assoc Nurses AIDS Care 1998; 9(3): dom and dual method use at last coitus among perinatally 48–58. https://doi.org/10.1016/S1055-3290(98)80019-8 and horizontally HIV-infected young women in Atlanta,   90. Bedimo AL, Bessinger R and Kissinger P. Reproductive Georgia. PLoS ONE 2018; 13(9): e0202946. choices among HIV-positive women. Soc Sci Med 1998; 107. Tote KM, Raziano VT, Wall KM, et al. Contraceptive 46(2): 171–179. method use among HIV-positive women in a US urban   91. Smits AK, Goergen CA, Delaney JA, et al. Contraceptive outpatient clinic: an exploratory cross-sectional study. use and pregnancy decision making among women with Contraception 2018; 98(6): 492–497. HIV. AIDS Patient Care STDS 1999; 13(12): 739–746. 108. Cohn SE, Haddad LB, Sheth AN, et al. Parenting desires   92. Sowell RL, Phillips KD and Misener TR. HIV-infected among individuals living with human immunodeficiency women and motivation to add children to their families. J virus in the United States. Open Forum Infect Dis 2018; Family Nurs 1999; 5: 316–331. 5(10): ofy232.   93. Vitiello MA and Smeltzer SC. HIV, pregnancy, and zido- 109. Gursahaney PR, Cordes S, Ofotokun I, et al. Factors vudine: what do women know. J Assoc Nurses AIDS Care associated with condom use among HIV-positive women 1999; 10(4): 41–47. living in Atlanta, Georgia. PLoS ONE 2019; 14(12):   94. Chen JL, Phillips KA, Kanouse DE, et al. Fertility e0225406. desires and intentions of HIV-positive men and women. 110. Dehlendorf C, Rodriguez MI, Levy K, et al. Disparities Fam Plan Perspect 2001; 33(4): 144–165. https://doi. in family planning. Am J Obstet Gynecol 2010; 202: 214– org/10.2307/2673717 220.   95. Bedimo-Rung AL, Clark AR, Dumestre J, et al. 111. Ippoliti NB, Nanda G and Wilcher R. Meeting the repro- Reproductive decision-making among HIV-Infected ductive health needs of female key populations affected by women. J Natl Med Assoc 2005; 97: 1403–1410. HIV in low- and middle-income countries: a review of the   96. Heard I, Sitta R, Lert F, et al. Reproductive choice in men evidence. Stud Fam Plann 2017; 48(2): 121–151. and women living with HIV: evidence from a large repre- 112. Amutah NN, Gifuni J and Wesley Y. Shaping the con- sentative sample of outpatients attending French hospitals versation: a secondary analysis of reproductive deci- (ANRS-EN12-VESPA Study). AIDS 2007; 21(Suppl 1): sion-making among Black mothers with HIV. Clin Med S77–S82. Insights Womens Health 2016; 9(Suppl1): 1–8.   97. Stanwood NL, Cohn SE, Heiser JR, et al. Contraception 113. Levine C and Dubler NN. Uncertain risks and bitter reali- and fertility plans in a cohort of HIV-positive women in ties: the reproductive choices of HIV-infected women. care. Contraception 2007; 75(4): 294–298. Milbank Q 1990; 68(3): 321–351.   98. Polzer Casarez RL and Miles MS. Spirituality: a cultural 114. Craft SM, Delaney RO, Bautista DT, et al. Pregnancy strength for African American mothers with HIV. Clin decisions among women with HIV. AIDS and Behavior Nurs Res 2008; 17(2): 118–132. 2007; 11: 927–935. Huertas-Zurriaga et al. 15 115. Fletcher FE, Ingram LA, Kerr J, et al. “She told them, American women. Psychol Women Quart 2020; 44: 84– oh that bitch got AIDS”: experiences of multilevel HIV/ 104. AIDS-related stigma among African American women 124. National Alliance on Mental Illness. Black/African living with HIV/AIDS in the South. AIDS Patient Care American, https://nami.org/Your-Journey/Identity-and STDS 2016; 30(7): 349–356. -Cultural-Dimensions/Black-African-American (2021, 116. Pivnick A, Jacobson A, Eric K, et al. Reproductive decisions accessed 16 June 2021). among HIV-infected, drug-using women: the importance of 125. Kozhimannil KB, Trinacty CM, Busch AB, et al. Racial mother-child coresidence. Med Anthropol Quart 1991; 5: and ethnic disparities in postpartum depression care among 153–169. low-income women. Psychiatr Serv 2011; 62(6): 619–625. 117. Salters K, Loutfy M, de Pokomandy A, et al. Pregnancy 126. Waldron EM, Burnett-Zeigler I, Wee V, et al. Mental incidence and intention after HIV diagnosis among health in women living with HIV: the unique and unmet women living with HIV in Canada. PLoS ONE 2017; needs. J Int Assoc Provid AIDS Care 2021; 20: 1–18. 12(7): e0180524. 127. Ward EC and Heidrich SM. African American women’s 118. Maccarthy S, Rasanathan JJ, Crawford-Roberts A, et al. beliefs about mental illness, stigma, and preferred coping Contemplating abortion: HIV-positive women’s decision behaviors. Res Nurs Health 2009; 32(5): 480–492. to terminate pregnancy. Cult Health Sex 2014; 16(2): 128. World Health Organization. Maintaining and improv- 190–201. ing quality of care within HIV clinical services. Geneva: 119. Njie-Carr V, Sharps P, Campbell D, et al. Experiences of WHO Press, 2019. HIV-positive African-American and African Caribbean 129. Rice WS, Logie CH, Napoles TM, et al. Perceptions of childbearing women: a qualitative study. J Natl Black intersectional stigma among diverse women living with Nurses Assoc 2012; 23(1): 21–28. HIV in the United States. Soc Sci Med 2018; 208: 9–17. 120. de Bruyn M. Safe abortion for HIV-Positive women with 130. Aziz M and Smith KY. Challenges and successes in link- unwanted pregnancy: a reproductive right. Reprod Health ing HIV-infected women to care in the United States. Clin Matters 2003; 11(22): 152–161. Infect Dis 2011; 52: S231–S237. 121. Sowa NA, Cholera R, Pence BW, et al. Perinatal depres- 131. Wesley Y, Smeltzer SC, Redeker NS, et al. Reproductive sion in HIV-infected African women: a systematic review. decision making in mothers with HIV-1. Health Care J Clin Psychiatry 2015; 76(10): 1385–1396. Women Int 2000; 21(4): 291–304. 122. Fried EI. Problematic assumptions have slowed down 132. Rueda S, Mitra S, Chen S, et al. Examining the associa- depression research: why symptoms, not syndromes tions between HIV-related stigma and health outcomes in are the way forward. Frontiers in Psychology 2015; 6: people living with HIV/AIDS: a series of meta-analyses. 309. BMJ Open 2016; 6: e011453. 123. Liao KY-H, Wei M and Yin M. The misunderstood 133. Barr D, Odetoyinbo M, Mworeko L, et al. The leader- schema of the strong black woman: exploring its mental ship of communities in HIV service delivery. AIDS 2015; health consequences and coping responses among African 29(Suppl. 2): S121–S127.