Background: Although there is evidence that adolescents with Perinatally-Acquired HIV (PHIV) are living into young adulthood, there is paucity of research about their fertility intentions and how the experiences of growing up with HIV influence their intentions for parenting. This is despite South Africa being the country with the largest number of children and adolescents on Antiretroviral Therapy (ART). The study explores motherhood desires, motivations and concerns of female adolescents with PHIV and assessed their awareness and understanding of Perinatal HIV Transmission (PHT). Methods: In-depth interviews were conducted with a purposively selected sample of 30 female adolescents with PHIV aged 14-19 years. The adolescents were enrolled in an ART program of a district hospital in Gauteng province, South Africa. Data were analyzed thematically using NVivo data analysis software. Findings: Most female adolescents with PHIV who perceived a low risk of PHT desired to have children. The desire for motherhood superseded the fear of PHT. However, parenting related issues such as the intention to disclose their HIV-positive status to their children was a great concern. The fear of PHT during pregnancy and fear of premature death leaving their children orphaned was the greatest concern among adolescents who did not desire to have children. On the other hand, the thoughts of having children for some adolescents was farfetched, for them, completing school and having a career was more important than having children. Conclusion: The heightened fear of PHT underscores the importance of educating children and adolescents with PHIV about the prevention of perinatal transmission of HIV. It is crucial that regular discussions on fertility desires, disclosure, and prevention of PHT are integrated in the daily counseling and support for children and adolescents with PHIV.