Reviewer ’s report  
 
Title: Factors related to fertility desire among female sex workers living with HIV in the 
Dominican Republic  
 
Version: 2 Date: 11 Dec 2017  
 
Reviewer: Susan Cohn  
 
Reviewer's report:  
 
Review  of Factors related to fertility desire among female sex workers living with HIV in the 
Dominican Republic  
 
Overview  
This paper addresses an important topic of fertility desires among female sex workers living with 
HIV, a group of women that tend to be mar ginalized with suboptimal access to the health care 
system. This cross -sectional study examined factors associated with wanting more children in the 
future.  Although this paper found some important associations and highlights additional factors 
worth expl oring in future research, it suffers from not being clear about some of their variables, 
and not presenting their data in a way that is easy for the reader to understand.  
 
Abstract  
The main research findings found in their multivariate regression analyses are not presented in 
such a way that the reader understands what the relationship were of the key variables and their 
primary outcome, fertility desire. "Multivariate regression results showed significant associations 
between fertility desire and older age , higher HIV -related internalized stigma, history of 
pregnancy loss, current number of children and perception of partner's feelings about 
pregnancy."  This sentence suggests that, for example, older age is associated with increased 
fertility desires, whic h is not want they found in this paper.  It would be better to describe not 
only the variables but the direction of the variable associated with fertility desires.  
The c onclusion is not supported within this paper since "multi -level stigma interventions" are 
needed but they were not discussed or addressed in this study. The conclusion should be 
rewritten to reflect what they found and what additional research is needed in the future.  
 
 
Background  
Would emphasize that if female sex workers (FSW) living with  HIV have children, they need 
health care services to control their HIV infection, prevent transmission to their offspring and 
prevent HIV from being passes on to their sex partners. They mention what the literature has 
found and they should more adequatel y describe their findings in the discussion and how similar 
their findings are from FSW with HIV to what has been described before in other populations.  
Also, they should clarify whether the findings of stigma say among health care providers (not 
being su pportive of childbearing among women with HIV) have changed in the era of effective 
ART. Studies have shown that pregnancy rates of women with HIV currently is similar to the 
rates among women at risk for HIV (WIHS data).  
The paper might be strengthened b y discussing the current health care access of the FSW.  Since 
the majority had children many after learning of their HIV and many are said to have "permanent 
sterilization", their relationship to the health care system and their ease of getting ART and ot her 
needed health care access may play a role in their decision whether to have children in the future. 
Unclear whether their responses about health care/provider stigma reflects recent experiences of 
experiences when they first were identified with HIV, a nd whether things have changed over the 
past decade in DR. Are all women with HIV eligible for life long ART?  
 
Methods  
The first line of the methods is misleading.  The authors present a cross -sectional, one time look 
at fertility desires (and other varia bles) among women who are part of a "multi -level 
intervention" which is not described. Data appears to be from the FSW's enrollment into this 
longitudinal study. This co -enrollment might suggest that these FSW may not be representative 
of all FSW living wi th HIV in the DR.  
This study would be strengthened by describing where the participants were enrolled from 
(health care facilities/HIV clinics vs peer referrals) and then how their responses different by 
mode of recruitment.  
A major concern is how their key variables were defined. What consists "permanent 
sterilization"? Were any of these substantiated by chart review? Had they had tubal ligations?  
Other studies have shown that women often are not fully aware of these procedu res when they 
have been done, and do not mention it when asked about the forms of contraception they are 
using. Do FSW think that they have been "permanently sterilized" because they have not become 
pregnant recently?  Could they have decreased fertility d ue to recurrent STI?  
Were mass sterilization going on in DR resulting in marginalized women being sterilized? Are 
LARC and other effective contraception available to marginalized women in DR?  
The other variable of concern is "pregnancy loss"?  Having 64 % of their FSW having had 
pregnancy loss seems unusually high.  What were the circumstances?  How many had 
spontaneous miscarriages? They describe "Child loss" but this is different from "pregnancy loss".  
How many had their older children die from acciden ts, trauma, or other reasons? Would the 
participant assume that if they just missed a period that they had lost a pregnancy? Without more 
description, it is hard to interpret what this variable implies.  
The survey is said to include the participants' hea lth care services used and whether they had 
disclosed their HIV status, both of which might influence their fertility desires, but not presented.  
During the paper, they sometimes refer to pregnancy "intentions" but it really is fertility desires.  
Data el ements often described in broad areas and not all the variables are described in detail, 
how they are define using which questions.  
 
Results  
When 200 women reported contraception use many of whom reported having "permanent 
sterilization", it raises the qu estion of the accuracy of the data or the interpretation of the 
questions by the study population. They do not describe the contraception use in this population 
which would be interesting. What is meant by "Permanent contraception" in Table 2?  Would 
defin e it first in the Methods section.  
Table 1 would be stronger if they were to include site of enrollment by the FSW (as above).  
Also, type or "permanent contraception". Would use "reported permanent contraception" for this 
variable if not able to be verif ied/validated.  
How was sterilization procedure reported? Tube tied? Was if verified even in small sample?  
Was it "reported sterilization procedure" by the FSWs?Prior studies have shone that women are 
often not aware that a tubal was done.  Didthey think there were sterilized because they were 
unableto get pregnant?  Were mass sterilaztion going on in DR resulting in marginalized women 
being sterilized? Are LARC and other effective contraception available to marginalized women 
in DR?  
p.10 Line 184 Please clarify pregnancy loss versus child loss.  
Numbers off by 1:  125 not sterilization + 115 "sterilized"+8 hyst= 248 YET Sample said to be 
247. Was a patient counted twice?  
Table 1 p. 9 Were "work locations" supposed to be unique (either Establishment or st reet)? The 2 
added up to 289 versus 247 in total population  
P 11 Line 200 Unclear. Presumably "the outcome" is fertility desire. Conversely, +VL associated 
with fertility desire.   
P.11 Line 211 Older age, having more kids, longer hx of HIV, on ART all associated with 
fertility desire but not clear the direction of the associations in the line (p.211 -215) Can be easily 
misinterpreted.  
Table  3.  Since it appears that they used p <.10 to select their variable, I would add those 
variables that were retained.  
P12 Line 221 Similar concern that the variable missed do not have the direction of the 
association.  
Table 4 a bit confusing with the 2 variables marked 1.00 (Perceived little/Perce ived partner  
P. 13 line 237 does not reveal the direction and hence confusing  
Would have been good to know if their partners were relatively new and if they had had a child 
with that partner since data had shown that women with new partners are most like ly to prefer 
having children in the future.  
Why does Table 4 not include ART use especially since it was significant predictor at the p <05?  
Table 3 Should add DK spelled out to the bottom as a table of abbreviation  
They talk about strict abortion laws but how widely available are birth control methods? Are 
they available for free to most women?  
 
Discussion  
P 14 Line 257 As above need more information on the "permanent contraception" procedure.  
P 15 Line 274 Note the factor (in this case HIV internalize d Stigma) does not have to be 
significant (presumably at the p<.05) just an associated of p <0.1 as described in the methods 
section.  
How was sterilization procedure reported? Tube tied? Was it verified even in small sample?  
Was it "reported sterilizatio n procedure" by the FSWs? Prior studies have shown that women are 
often not aware that a tubal was done.  Did they think there were sterilized, for example  because 
they were unable to get pregnant?  Were mass sterilization going on in DR resulting in 
marg inalized women being sterilized? Are LARC and other effective contraception available to 
marginalized women in DR? This information would be helpful to understand what was 
evaluated and how to interpret it.  
They mention "access to care" but not a variable  described in the manuscript, or associated with 
fertility desires.  
Permanent contraception: If a third of women who have been sterilized now want more children, 
this is a significant problem. I think  their statement on p 14 Line 258 "which may be of con cern" 
is a significant understatement.  
p 15 Line 274 "may have been exposed to…"  
p/15 Line 280 "has been found to have a "  
They found FSW on current ART less likely to want more children and yet if on ART, they may 
also  have better access to care which has in other studies been associated with increase fertility 
rates.  Not well understood, but probably less important since i t was not a predictor either way in 
the multivariable analyses.  
Pregnancy loss variable not adequately defines and hence less helpful.  Even though there are 
strict abortion laws, do pregnant women obtained abortions, perhaps not in main stream facilities  
(Backroom abortions)?  
 
Limitations  
Agreed that where the women were recruited from could affect the results.  Would have liked to 
see the breakdown, and even look at the results from the 2 recruitment strategies: peer navigator 
initiated referrals vs Heal th care facilities  
Pregnancy loss variable and sterilization are the largest unknown in this dataset/study, and not 
certain how well they have been characterized/verified.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
  
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?   
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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