{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T22:29:20Z","timestamp":1785882560755,"version":"3.56.0"},"reference-count":37,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2023,2,21]],"date-time":"2023-02-21T00:00:00Z","timestamp":1676937600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Sub-Saharan Africa (SSA) has the highest fertility rates and highest HIV disease burden globally. However, it is not clear how the rapid expansion of anti-retroviral therapy (ART) for HIV has impacted the fertility gap between HIV-infected and uninfected women. We used data from a Health and Demographic Surveillance System (HDSS) in north-western Tanzania to explore trends in fertility rates and the relationship between HIV and fertility over the 25-year period.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>From 1994 to 2018, births and population denominators from the HDSS population were used to obtain age-specific fertility rates (ASFRs) and total fertility rates (TFRs). HIV status was extracted from eight rounds of epidemiologic serological surveillances (1994\u20132017). Fertility rates by HIV status and in different levels of ART availability were compared over time. Independent risk factors for fertility changes were examined using Cox proportional hazard models.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>There were 24,662 births from 36,814 women (15\u201349) who contributed a total of 145,452.5 Person-Years of follow-ups. The TFR declined from 6.5 births per woman in 1994\u20131998 to 4.3 births per woman in 2014\u20132018. The number of births per woman was 40% lower in women living with HIV than in HIV-uninfected women (4.4 vs. 6.7), although this difference narrowed over time. The fertility rate in HIV-uninfected women was 36% lower in 2013\u20132018 than in 1994\u20131998(age-adjusted HR = 0.641; 95% CI 0.613\u20130.673). In contrast, the fertility rate in women living with HIV was relatively unchanged over the same follow up period (age-adjusted HR = 1.099; 95% CI 0.870\u20131.387).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>There was a notable fertility decline among women in the study area from 1994 to 2018. Fertility remained lower in women living with HIV than in HIV-uninfected women, but the difference continued to narrow over time. These results highlight the need for more research into fertility changes, fertility desire and family planning use in Tanzanian rural communities.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0281914","type":"journal-article","created":{"date-parts":[[2023,2,21]],"date-time":"2023-02-21T19:01:24Z","timestamp":1677006084000},"page":"e0281914","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":8,"title":["Fertility trends by HIV status in a health and demographic surveillance study in Magu District, Tanzania, 1994\u20132018"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6883-1431","authenticated-orcid":true,"given":"Denna","family":"Mkwashapi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jenny","family":"Renju","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Mahande","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Changalucha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Urassa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jim","family":"Todd","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2023,2,21]]},"reference":[{"key":"pone.0281914.ref001","unstructured":"United Nation, Department of Economic and Social Affairs. Population Dision (2020), World Fertility 2019. Early and late childbearing among adolescent women (ST\/ESA\/SER.A\/446)."},{"issue":"16","key":"pone.0281914.ref002","article-title":"Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) and I","volume":"2015","year":"2016","journal-title":"Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS)"},{"issue":"2","key":"pone.0281914.ref003","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1017\/S0021932003001895","article-title":"The association between HIV and fertility in a cohort study in rural Tanzania.","volume":"35","author":"SC Hunter","year":"2003","journal-title":"J Biosoc Sci."},{"issue":"7","key":"pone.0281914.ref004","first-page":"908","article-title":"If I don\u2019t have children, they will know that I\u2019m sick\u201d: fertility desires of women and men living with HIV in Iringa, Tanzania","volume":"31","author":"H. T. Saleem","year":"2019","journal-title":"AIDS Care\u2014Psychological and Socio-Medical Aspects of AIDS\/HIV"},{"key":"pone.0281914.ref005","first-page":"1","article-title":"Data 2017.","author":"UNAIDS","year":"2017","journal-title":"Program HIV\/AIDS"},{"key":"pone.0281914.ref006","article-title":"December 2017 Tanzania Hiv Impact Survey.","author":"United Republic of Tanzania","year":"2017"},{"key":"pone.0281914.ref007","doi-asserted-by":"crossref","first-page":"1241","DOI":"10.1016\/0140-6736(93)92225-I","article-title":"Procreation and HIV. Vol","author":"S Dublin","year":"1993","journal-title":"342, Lancet (London, England). England"},{"issue":"1","key":"pone.0281914.ref008","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1136\/sti.75.1.3","article-title":"From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection.","volume":"75","author":"DT Fleming","year":"1999","journal-title":"Sex Transm Infect."},{"issue":"4","key":"pone.0281914.ref009","doi-asserted-by":"crossref","first-page":"e019818","DOI":"10.1136\/bmjopen-2017-019818","article-title":"Cross-sectional study on the prevalence and predictors of pregnancy among women living in HIV discordant relationships in a rural Rakai cohort, Uganda.","volume":"8","author":"LJ Nakiganda","year":"2018","journal-title":"BMJ Open"},{"key":"pone.0281914.ref010","doi-asserted-by":"crossref","first-page":"S35","DOI":"10.1097\/00002030-200406002-00005","article-title":"The population impact of HIV on fertility in sub-Saharan Africa","volume":"2","author":"JJ Lewis","year":"2004","journal-title":"AIDS"},{"issue":"5","key":"pone.0281914.ref011","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1097\/00002030-200403260-00012","article-title":"HIV-1 disease progression and fertility: the incidence of recognized pregnancy and pregnancy outcome in Uganda","volume":"18","author":"A Ross","year":"2004","journal-title":"AIDS"},{"issue":"12","key":"pone.0281914.ref012","doi-asserted-by":"crossref","first-page":"1542","DOI":"10.1111\/tmi.12983","article-title":"The relationship between HIV and fertility in the era of antiretroviral therapy in sub-Saharan Africa: evidence from 49 Demographic and Health Surveys","volume":"22","author":"M Marston","year":"2017","journal-title":"Trop Med Int Health"},{"key":"pone.0281914.ref013","doi-asserted-by":"crossref","first-page":"S69","DOI":"10.1097\/QAD.0000000000001305","article-title":"The effects of HIV on fertility by infection duration: evidence from African population cohorts before antiretroviral treatment availability","volume":"31","author":"l Marston","year":"2017","journal-title":"AIDS"},{"issue":"2","key":"pone.0281914.ref014","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1111\/j.1365-3156.2005.01554.x","article-title":"Differences in fertility by HIV serostatus and adjusted HIV prevalence data from an antenatal clinic in northern Uganda","volume":"11","author":"M Fabiani","year":"2006","journal-title":"Trop Med Int Health"},{"issue":"9492","key":"pone.0281914.ref015","doi-asserted-by":"crossref","first-page":"1182","DOI":"10.1016\/S0140-6736(05)67481-8","article-title":"Increased risk of incident HIV during pregnancy in Rakai, Uganda: a prospective study","volume":"366","author":"RH Gray","year":"2005","journal-title":"Lancet"},{"issue":"4","key":"pone.0281914.ref016","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1097\/00002030-199903110-00011","article-title":"Impaired fertility in HIV-1-infected pregnant women: a clinic-based survey in Abidjan, C\u00f4te d\u2019Ivoire, 1997.","volume":"13","author":"A Desgr\u00e9es du Lo\u00fb","year":"1999","journal-title":"AIDS"},{"issue":"9","key":"pone.0281914.ref017","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1111\/tmi.12747","article-title":"Impact of ART on the fertility of HIV-positive women in sub-Saharan Africa","volume":"21","author":"S Yeatman","year":"2016","journal-title":"Trop Med Int Health"},{"issue":"3","key":"pone.0281914.ref018","doi-asserted-by":"crossref","first-page":"e0151877","DOI":"10.1371\/journal.pone.0151877","article-title":"Measuring the Impact of Antiretroviral Therapy Roll-Out on Population Level Fertility in Three African Countries","volume":"11","author":"M Marston","year":"2016","journal-title":"PLoS ONE"},{"issue":"3","key":"pone.0281914.ref019","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1097\/QAI.0000000000000963","article-title":"Untangling the Relationship Between Antiretroviral Therapy Use and Incident Pregnancy: A Marginal Structural Model Analysis Using Data From 47,313 HIV-Positive Women in East Africa","volume":"72","author":"B Elul","year":"2016","journal-title":"Journal of Acquired Immune Deficiency Syndromes (1999)"},{"issue":"81","key":"pone.0281914.ref020","article-title":"Increasing incidence of pregnancy among women receiving HIV care and treatment at a large urban facility in western Uganda.","volume":"11","author":"J. Kabami","year":"2014","journal-title":"Reprod Health"},{"issue":"3","key":"pone.0281914.ref021","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1016\/j.ijgo.2015.06.035","article-title":"Incident pregnancy and pregnancy outcomes among HIV-infected women in Uganda and Zimbabwe.","volume":"131","author":"KE Lancaster","journal-title":"Int J Gynaecol Obstet. 2015 Dec"},{"key":"pone.0281914.ref022","article-title":"The global AIDS Response Country progress report,.","author":"NACP","year":"2014","journal-title":"Tanzania Ministry of Health."},{"key":"pone.0281914.ref023","article-title":"National Guidelines for Management of HIV and AIDS.","author":"Ministry of Health, Community Development, Gender E and C (MoHCDGEC)","year":"2015","journal-title":"United Republic of Tanzania"},{"key":"pone.0281914.ref024","article-title":"Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) and I 2016","year":"2015\u20132016","journal-title":"Tanzania Demographic and Health Survey and Malaria Indicator Survey"},{"issue":"6","key":"pone.0281914.ref025","doi-asserted-by":"crossref","first-page":"1851","DOI":"10.1093\/ije\/dyv188","article-title":"Health & Demographic Surveillance System Profile: The Magu Health and Demographic Surveillance System (Magu HDSS).","volume":"44","author":"C Kishamawe","year":"2015","journal-title":"Int J Epidemiol"},{"issue":"5","key":"pone.0281914.ref026","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1097\/QAI.0b013e31815a571a","article-title":"HIV prevalence and incidence in rural Tanzania: results from 10 years of follow-up in an open-cohort study.","volume":"46","author":"M Wambura","year":"2007","journal-title":"J Acquir Immune Defic Syndr."},{"issue":"10","key":"pone.0281914.ref027","doi-asserted-by":"crossref","first-page":"1233","DOI":"10.1097\/00002030-199907090-00013","article-title":"Spread of HIV infection in a rural area of Tanzania","volume":"13","author":"JT Boerma","year":"1999","journal-title":"AIDS"},{"key":"pone.0281914.ref028","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1186\/s40834-019-0100-6","article-title":"Contraceptive use and discontinuation among women in rural North-West Tanzania.","volume":"4","author":"W. Safari","year":"2019","journal-title":"Contracept Reprod Med"},{"issue":"8","key":"pone.0281914.ref029","doi-asserted-by":"crossref","first-page":"2891","DOI":"10.1073\/pnas.1717288116","article-title":"Stalls in Africa\u2019s fertility decline partly result from disruptions in female education","volume":"116","author":"E Kebede","year":"2019","journal-title":"Proc Natl Acad Sci U S A"},{"key":"pone.0281914.ref030","article-title":"Accelerating fertility decline through education and family planning.","author":"AE Raftery","year":"2021","journal-title":"N-IUSSPORG."},{"issue":"3","key":"pone.0281914.ref031","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1111\/padr.12347","article-title":"How Do Education and Family Planning Accelerate Fertility Decline?","volume":"46","author":"DH Liu","year":"2020","journal-title":"Popul Dev Rev"},{"key":"pone.0281914.ref032","author":"Ministry of Education","year":"2014","journal-title":"Universal Secondary School Education in Tanzania"},{"key":"pone.0281914.ref033","article-title":"2012 Population and Housing Census.","volume":"IV","author":"United Republic of Tanzania","year":"2015"},{"issue":"4","key":"pone.0281914.ref034","first-page":"44","article-title":"Fertility, Family Size Preference and Contraceptive Use in Sub-Saharan Africa: 1990\u20132014.","volume":"22","author":"CO Odimegwu","year":"2018","journal-title":"Afr J Reprod Health"},{"issue":"4","key":"pone.0281914.ref035","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1097\/QAI.0000000000001395","article-title":"Changes in Fertility at the Population Level in the Era of ART in Rural Malawi.","volume":"75","author":"E McLean","year":"2017","journal-title":"J Acquir Immune Defic Syndr."},{"issue":"2","key":"pone.0281914.ref036","doi-asserted-by":"crossref","first-page":"e45","DOI":"10.1097\/QAI.0000000000000279","article-title":"Incidence of pregnancy after antiretroviral therapy initiation and associated factors in 8 West African countries.","volume":"67","author":"J Burgos-Soto","year":"2014","journal-title":"J Acquir Immune Defic Syndr."},{"issue":"9","key":"pone.0281914.ref037","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1371\/journal.pone.0222173","article-title":"Effect of antiretroviral therapy on fertility rate among women living with HIV in Tabora, Tanzania: An historical cohort study.","volume":"14","author":"G Mbita","year":"2019","journal-title":"PLoS One"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0281914","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,2,21]],"date-time":"2023-02-21T19:01:46Z","timestamp":1677006106000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0281914"}},"subtitle":[],"editor":[{"given":"Orvalho","family":"Augusto","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2023,2,21]]},"references-count":37,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2023,2,21]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0281914","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,21]]}}}