In many parts of sub-Saharan Africa, the majority of pregnancies among adolescents aged 19 years and below result from unplanned and unprotected sexual acts and are therefore mostly unintended [1–3]. In settings with high HIV prevalence such as Eastern and Southern parts of sub-Saharan Africa, this further predisposes the adolescents to the risk of acquiring sexually transmitted infections (STIs) including HIV and AIDS. HIV infection may in turn influence the fertility of individual women, including adolescents. For example, fertility among HIV-infected women may be reduced due to diminished fecundity, increased condom use to prevent further spread of infection, or reduced sexual activity, and it may increase especially when infected individuals are under societal pressure to have sex, reproduce, or replace those children who have died [4–6]. The possible pathways through which HIV and AIDS may influence fertility could also have different implications for fertility intentions of HIV-infected women. For instance, intention to have children might be reduced for individuals who experience diminished sexual activity while it might increase for those who want to replace infants who die.
Empirical evidence indicates that in some settings, individuals who test HIV-positive reduce their childbearing intentions [7, 8]. It therefore seems reasonable to suppose that in such settings, births to HIV-positive women are likely to be unintended. In other settings, the increased availability of antiretroviral treatment (ART) has been found to have a positive impact on future fertility intentions of HIV-positive individuals [9–11]. Thus, it should be expected that all factors constant, births to HIV-positive women in these settings are likely to be intended. Nonetheless, despite the increased availability of ART in parts of sub-Saharan Africa, there are reasons to suggest that unintended births might just be as common among HIV-infected adolescents as other young people in the region. For instance, recent evidence shows no significant difference in the sexual behaviour and childbearing experiences and intentions of those who were infected with HIV at birth and know their sero-status and their counterparts in the general population [12–14]. Moreover, reproductive health services in many parts of the region are not oriented towards adequately addressing the needs of adolescents partly because of weak health care systems and partly due to cultural disapproval of teenage sexuality [15–17].
Furthermore, there have been increased efforts to provide integrated reproductive health and HIV services in parts of the region as a means of improving clients’ access to both types of services [18–22]. This should in theory lead to improved reproductive health outcomes for HIV-positive clients, especially those who are on ART. However, most HIV services continue to be organized around paediatric or adult care [23, 24], which implies that where the services are integrated, they rarely benefit adolescent clients. This is also supported by recent evidence indicating that for HIV-positive adolescents who have regular contacts with clinics where they can obtain sexual and reproductive health (SRH) information and services, providers/counsellors often emphasize postponement of or restraint from sexual intercourse and do not screen for SRH needs in order to offer appropriate services [13, 23]. As a result, a large proportion of those who are sexually active do not use preventive methods to avoid undesired consequences such as unintended pregnancies, that is, pregnancies that occur earlier than desired (mistimed) or not wanted at all (unwanted) at the time of conception [12, 13, 23, 25].
Unintended pregnancies have in turn been associated with low use of maternal health care services and poor birth outcomes among some population sub-groups. Marston and Cleland  for instance found that in Peru, children unwanted at conception had poor outcomes while in the other countries considered in the study, unintended pregnancies were associated with low use of prenatal care. There is also evidence that in many parts of sub-Saharan Africa, adolescent girls who experience unintended pregnancies resort to unsafe abortion [3, 27–29]. HIV may further complicate the reproductive health outcomes of adolescents, for example, in terms of poor birth outcomes due to advanced infection especially among those who are not on ART. Moreover, experiencing repeated unintended pregnancies suggests increased exposure to unprotected sexual intercourse, which has health implications for HIV-positive individuals in terms of high risk of re-infection with another strain of the virus. Although the experiences of unintended pregnancies and poor birth outcomes among teenagers in the general population are well documented, there is limited understanding of the same among HIV-positive adolescents. This paper uses data on pregnancy histories of HIV-positive female adolescents aged 15–19 years in Kenya to examine the factors associated with experiencing unintended pregnancies, poor birth outcomes, and post-partum contraceptive use among this population sub-group.
Estimates from the 2008–2009 Kenya Demographic and Health Survey (KDHS) show that 18% of adolescent girls aged 15–19 years in Kenya had begun childbearing with marked variations by socio-economic characteristics . For instance, the proportion of adolescent girls who had begun childbearing was more than twice as high in Nyanza and Coast provinces compared to Central region (27%, 26% and 10% respectively). The corresponding figures for Rift Valley, North Eastern, Western, and Nairobi provinces are 17%, 16%, 15% and 14%. In addition, the proportion of adolescent girls with no education who had begun childbearing was three times higher than that of those with secondary and above education (32% and 10% respectively). At the same time, 12% of adolescent girls were married or living with a man at the time of the survey while 1% had been formerly married (divorced or separated).
Results of the 2008–2009 KDHS further show that the national HIV prevalence among adults aged 15–49 years was 6% . Prevalence was twice as high among women compared to men (8% and 4% respectively) and in Nyanza compared to Nairobi or Western provinces (14% in Nyanza compared to 7% in Nairobi and Western regions). The adult prevalence in the other regions was 5% in Rift Valley and Central, 4% in Coast and Eastern, and 1% in North Eastern province. The prevalence among adolescent boys and girls aged 15–19 years was much lower (2%) but still three times higher among girls compared to boys (3% and 1% respectively). It was also highest in Nyanza compared to other regions (6% in Nyanza compared to less than 1% in Nairobi and Eastern provinces, 1% in Central, Coast, Rift Valley and Western provinces, and 2% in North Eastern province).
Although ART was introduced in Kenya in the 1990s, the 2010 Kenya Service Provision Assessment (KSPA) found that only 16% of all health facilities were offering ART services . The proportion of facilities offering the services ranged from 9% in North Eastern to 24% in Coast, 31% in Nyanza, and 33% in Nairobi partly reflecting the prevalence of HIV in these regions. Nonetheless, only 11% of the health facilities in Rift Valley offered the services despite the fact that HIV prevalence in the region is comparable to that of Coast province. The number of adults and children living with HIV in the country was estimated at 1.5 million by the end of 2009 while 61% of those in need of ART were receiving the services by the end of 2010 [32, 33]. The proportion of health facilities in the country that offer HIV testing services is also high (74%) while nearly two-thirds (64%) offer care and support services for HIV-positive clients .
The process of integrating reproductive health and HIV services started in Kenya more than a decade ago with initial efforts focusing on integrating counselling and testing for HIV into prenatal care services [18, 34]. Subsequent efforts included integrating family planning into voluntary counselling and testing for HIV as well as integrating counselling and testing into family planning services. However, it was not until 2009 that the Government finalized a national strategy for integrating the two types of services with the aim of improving the coordination and collaboration among key agencies and organizations involved in the provision of the services . In spite of these efforts, the 2010 KSPA showed that of the health facilities offering prevention of mother-to-child transmission (PMTCT) of HIV services, for instance, only 33% offered the minimum package that includes testing, ART, counselling on maternal nutrition and infant feeding as well as family planning counselling or referral .