Perceived effect of HIV status and ART treatment on fecundity in sub-Saharan Africa: Findings from a systematic scoping review

Abstract Background: Advances in antiretroviral therapy (ART) enable women living with HIV to safely conceive and give birth without vertical transmission. However, in sub-Saharan Africa, 1 in 5 couples experience infertility and women living with HIV face even higher rates. Several longitudinal studies show that ART and virologic suppression improve fertility/fecundity, yet this benefit is often overlooked in ART adherence education. Objectives: The objective of this scoping review is to map the literature on people’s understandings and beliefs of; 1) the relationship between HIV and fecundity, and 2) the effectiveness of ART in reducing HIV's adverse impact on fecundity. We also documented suggestions for interventions to raise awareness around how HIV and ART affect fecundity. Study Design: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct a scoping systematic search of English and French literature in sub-Saharan Africa from 2000–2024 with keywords related to HIV, ART, and fecundity/fertility. Three independent reviewers screened texts, read a subset of full texts, and used a charting table to summarize results and identify emerging themes. Principal Findings: Of 1,981 sources identified, only 12 met our inclusion criteria. Most did not explicitly examine perceptions of HIV, ART, and fecundity but related topics. Despite the scarcity of research, we uncovered the following themes: (1) Beliefs that HIV and PrEP cause infertility exist but have not been widely documented; (2) Perceptions that ART improves health before pregnancy motivates women to adhere and provides hope about future pregnancy; (3) Stigma from providers discourages women living with HIV from seeking preconception care; and (4) Lack of awareness among providers and patients about the impact of HIV on pregnancy, highlights the need for provider training. Conclusions & Implications for Policy and Practice: Research on perceptions of HIV, ART, and fecundity in sub-Saharan Africa is sparse despite evidence that HIV reduces fecundity while ART increases the likelihood of pregnancy. Given the cultural importance of motherhood and the stigma associated with infertility in sub-Saharan Africa, addressing this gap could improve ART adherence and help couples living with HIV build their families.