Life after HIV: examination of HIV serodiscordant couples' desire to conceive through assisted reproduction

Discussing parenthood with gay men diagnosed with HIV: a qualitative study of patient and healthcare practitioner perspectives

BACKGROUND

Research on HIV and reproduction has focused largely on women and heterosexual men. This article examines whether it is relevant to address parenthood in HIV care with gay men and what ways of doing so are most appropriate.

METHODS

Qualitative interviews were conducted at four London clinics with 25 men living with HIV, aged 20-45, who did not have children, and 16 HIV clinicians. A thematic analysis identified potential reasons why parenthood was rarely discussed with gay men in HIV care.

RESULTS

Two sets of ideas contributed to a lack of conversations about parenthood: clinicians' ideas about what matters to gay men and men's ideas about what it means to be HIV-positive. Both sets of ideas largely excluded having children, with patients and practitioners similarly unlikely to raise the topic of parenthood in the clinic. Contrary to what clinician commonly assumed, many men expressed interest in receiving more information, highlighting the importance of reassuring people upon diagnosis that it is possible to become parents while living with HIV.

CONCLUSIONS

Parenting desires and intentions were rarely discussed with men in HIV care. Our findings illuminate the potentially beneficial effects of emphasising that having children is a possibility at diagnosis, regardless of patients' gender or sexuality. Conveying this information seems meaningful, not only to men who want to become parents in the future but also to others, as it appears to alleviate fears about mortality and ill health.

Prevalence and factors associated with fertility desires/intentions among individuals in HIV-serodiscordant relationships: a systematic review of empirical studies

INTRODUCTION

Better knowledge about fertility desires/intentions among HIV-serodiscordant partners who face unique challenges when considering childbearing may be helpful in the development of targeted reproductive interventions. The aim of this systematic review was to synthesize the published literature regarding the prevalence of fertility desires/intentions and its associated factors among individuals in HIV-serodiscordant relationships while distinguishing low- and middle-income countries (LMIC) from high-income countries (HIC).

METHODS

A systematic search of all papers published prior to February 2017 was conducted in four electronic databases (PubMed/MEDLINE, PsycINFO, Web of Science and Cochrane Library). Empirical studies published in peer-reviewed journals with individuals in HIV-serodiscordant relationships assessing the prevalence of fertility desires/intentions and/or the associated factors were included in this systematic review. This review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS AND DISCUSSION

After screening 1852 references, 29 studies were included, of which 21 were conducted in LMIC and eight in HIC. A great variability in the prevalence of fertility desires/intentions was observed in LMIC (8% to 84% (one member of the dyad included)). In HIC, the results showed a smaller discrepancy between in the prevalence (32% to 58% (one member of the dyad included)); the prevalence was higher when the couple was the unit of analysis (64% to 73%), which may be related to the fact that all these studies were conducted in the context of assisted reproduction. Few studies examined the factors associated with fertility desires/intentions, and all except one were conducted in LMIC. Individuals (e.g. number of children), couple-level (e.g. belief that the partner wanted children) and structural factors (e.g. discussions with health workers) were found to be associated.

CONCLUSIONS

The results of this systematic review suggest that many individuals in HIV-serodiscordant relationships have fertility desires/intentions, although the prevalence is particularly heterogeneous in LMIC in comparison to HIC. Well-known factors such as younger age and a fewer number of living children were consistently associated with increased fertility desires/intentions. Different couple-level factors emerged, reflecting the importance of considering both the individual and the couple. However, further studies that specifically focus on the dyad as the unit of analysis are warranted.

Reproductive Desires and Considerations of HIV-Positive Men in Heterosexual Relationships in New York City

The reproductive desires of HIV-positive men have been investigated far less than those of HIV-positive women, especially in the US. This qualitative study of a sample of 94 HIV-positive men in New York City who were in a relationship with a woman of reproductive age examined their reasons for wanting a child as well as the conditions under which they would feel ready to attempt conception. Participants felt a child would make them feel normal, give meaning to their lives, or make others in their life happy. Although they reported HIV-related concerns (i.e., horizontal or vertical transmission, reinfection, or shortened life expectancy), participants mostly discussed factors unrelated to HIV (e.g., finances, housing, incarceration, substance abuse, or relationships) as deterrents to acting on their desire to having a child. When providing information on safer conception, healthcare providers should be aware of the broad desires and factors informing HIV-positive men's reproductive goals.

Fertility intentions of prenatal and postpartum HIV-positive women in primary care in Mpumalanga province, South Africa: a longitudinal study

Introduction

This study aimed to assess fertility intentions (planning to have more children in the future) and associated factors among pregnant and postpartum HIV positive women in rural South Africa.

Methods

In a longitudinal study, as part of a prevention of mother to child transmission (PMTCT) intervention trial, 699 HIV positive prenatal women, were systematically recruited and followed up at 6 months and 12 months postpartum (retention rate = 59.5%).

Results

At baseline, 32.9% of the women indicated fertility intentions and at 12 months postnatal, 120 (28.0%) reported fertility intentions. In longitudinal analyses, which included time-invariant baseline characteristics predicting fertility intention over time, not having children, having a partner with unknown/HIV-negative status, and having disclosed their HIV status to their partner, were associated with fertility intentions. In a model with time-varying covariates, decreased family planning knowledge, talking to a provider about a future pregnancy, and increased male involvement were associated with fertility intentions.

Conclusion

Results support ongoing perinatal family planning and PMTCT education.

Role of HIV in the desire of procreation and motherhood in women living with HIV in Spain: a qualitative approach

Background

Improved antiretroviral treatments and decrease in vertical transmission of HIV have led to a higher number of women living with HIV to consider childbearing. However, stigma and social rejection result in specific challenges that HIV positive women with procreation intentions have to face with. Our objective was to in depth analyse elements shaping their desire for procreation and specifically investigate the impact of HIV.

Methods

A qualitative study was conducted through open interviews with 20 women living with HIV between 18 and 45 years of age, from the Spanish AIDS Research Network Cohort (CoRIS). Interviews were audio-recorded and transcribed. A content analysis was performed.

Results

HIV diagnosis is a turning point in women’s sexual and emotional life that is experienced traumatically. HIV diagnosis is usually associated with the fear of an immediate death and the idea of social isolation. At this moment, women temporarily reject future motherhood or having a sexual life. HIV status is only disclosed to the closed social circle and partner support is essential in HIV diagnosis assimilation process. Health professionals provide information on assisted reproductive technology and on how to minimize risk of partner HIV transmission. Most of barriers for procreation acknowledged by women are not related to HIV. However, women fear vertical transmission and experience other barriers derived from HIV infection. In this context, pregnancy makes women feel themselves as “normal women” despite HIV. Motherhood is considered an element of compensation that helps them to cope with HIV diagnosis. All these elements make health professionals key actors: they provide information and support after HIV diagnosis.

Conclusions

Barriers and drivers for procreation are similar among HIV positive women and general population. However, stigma and discrimination linked with HIV weigh in HIV positive women decision of motherhood. In this context, it is necessary to provide these women with the necessary counselling, guidance and resources to take decisions about procreation properly informed.

Electronic supplementary material

The online version of this article (10.1186/s12905-017-0483-y) contains supplementary material, which is available to authorized users.

"Is It All Right for Me to Have a Baby or Not?": Men Living With HIV Discuss Fertility Desires and Interactions With Providers

To our knowledge, no study in the United States has qualitatively examined fertility desires, experiences communicating with health care providers about sexual and reproductive health, and attitudes toward reproductive counseling and services in men living with HIV (MLWH) who have sex with women. We conducted focus groups and interviews with MLWH (N = 17) who have sex with women seeking HIV care in San Francisco. The men conveyed limited awareness of safer conception strategies. While many men expressed the desire to have a child, most reported that their providers had not discussed reproduction with them. Participants highlighted the lack of HIV services for men who have sex with women and the need for improved reproductive counseling. We make recommendations for providers who work with MLWH who have sex with women and for patient-centered materials on safer conception, sexual HIV transmission risk reduction, and family planning strategies.

"Everything I Needed from Her Was Everything She Gave Back to Me:" An Evaluation of Preconception Counseling for U.S. HIV-serodiscordant Couples Desiring Pregnancy

OBJECTIVES

We sought to evaluate preconception counseling (PCC) through a qualitative examination of the experiences of couples with serodiscordant human immunodeficiency virus (HIV) status desiring pregnancy.

METHODS

Patients involved in HIV-serodiscordant relationships who received PCC between January 2013 and January 2015 were recruited to participate in 40-minute semistructured telephone interviews. Participants were asked about their experiences with PCC and the impact of counseling on their knowledge of safer conception strategies and reproductive decisions. Two researchers independently coded interview transcripts, and delineated common ideas to generate emerging themes from participants' responses.

RESULTS

Eleven respondents completed the interviews, including nine women and two men. Six respondents were HIV positive. Our thematic analysis revealed that patients gained knowledge and confidence through PCC that conception was both possible and safe. They had varied reactions to assisted reproductive technologies that correlated with income level, and explored complicated weighing of personal risk of HIV transmission. Patients reported major challenges including poor access to PCC, difficulty identifying peak fertility periods, and lack of long-term conception follow-up.

DISCUSSION

PCC is a valuable resource for patients involved in HIV-serodiscordant relationships. We recommend the following opportunities for improvement: developing practical safer conception clinical and counseling guidelines for HIV-affected couples, increasing patient access to and awareness of PCC services, distributing more helpful resources to identify peak fertility, and providing long-term support for patients.

PREVALENCE AND FACTORS ASSOCIATED WITH PATERNITY INTENTION AMONG MEN LIVING WITH HIV/AIDS IN FORTALEZA, CEARÁ

The aim of this study was to analyze the prevalence and factors associated with paternity intention in 162 men with HIV/AIDS in Fortaleza, Ceará. Data were collected from June to September 2012 using a questionnaire in reference outpatient centers. Pearson's chi-squared test and logistic regression model were used for analysis. In all, 41.4% of men had the intention to have children. Age <35 years (p<0.001), desire to have children before diagnosis (p<0.001), relationship for less than five years (p=0.022), partner's desire to have children (p<0.001), having no children with the partner (p=0.047), partner without children (p=0.032) and therapy for more than three years (p=0.030) presented significant statistical association with men's desire to have children. In the multivariate analysis, the desire to have children before diagnosis (p=0.004; OR:9.81; CI:1.84-52.20) and partner's desire to have children (p<0.001; OR:9.72; CI:3.48-27.12) remained statistically significant. Many men still intend to be fathers even after the HIV/AIDS diagnosis.

Natural Conception May Be an Acceptable Option in HIV-Serodiscordant Couples in Resource Limited Settings

Many HIV serodiscordant couples have a strong desire to have their own biological children. Natural conception may be the only choice in some resource limited settings but data about natural conception is limited. Here, we reported our findings of natural conception in HIV serodiscordant couples. Between January 2008 and June 2014, we retrospectively collected data on 91 HIV serodiscordant couples presenting to Beijing Youan Hospital with childbearing desires. HIV counseling, effective ART on HIV infected partners, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) in negative female partners and timed intercourse were used to maximally reduce the risk of HIV transmission. Of the 91 HIV serodiscordant couples, 43 were positive in male partners and 48 were positive in female partners. There were 196 unprotected vaginal intercourses, 100 natural conception and 97 newborns. There were no cases of HIV seroconversion in uninfected sexual partners. Natural conception may be an acceptable option in HIV-serodiscordant couples in resource limited settings if HIV-positive individuals have undetectable viremia on HAART, combined with HIV counseling, PrEP, PEP and timed intercourse.

A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings

BACKGROUND

While HIV incidence has stabilized in many settings, increases in health and wellbeing among many people living with HIV/AIDS suggest that the number of HIV-serodiscordant relationships is growing. Given the deficit of reviews addressing social and behavioural characteristics of HIV-serodiscordant couples within high-income settings, our objective was to understand the scope of the published literature, identify evidence gaps, and suggest future research needs.

METHODS

Ten electronic databases were searched. Studies were included if they were reported in English, used primary data, were from the combination antiretroviral (cART) era (>1996), reported on social or behavioural aspects, included any fraction of primary (i.e., stable) relationships, and were conducted in high-income settings. Studies that identified their unit of analysis as either the dyad or individual member of the couple were included. Studies were coded according to a thematic framework.

RESULTS

Included studies (n = 154) clustered into eight themes: risk behaviours (29%), risk management (26%), reproductive issues (12%), relationship quality (9%), serostatus disclosure (7%), adherence to antiretroviral therapy (7%), vulnerability (5%), and social support (3%). The proportion of studies conducted among heterosexual couples, same-sex male couples, and mixed cohorts were 42%, 34%, and 24%, respectively. Most studies (70%) were conducted in the United States, 70% of all studies were quantitative (including interventions), but only one-third were focused on couples (dyads) where both partners are recruited to a study. Over 25% of studies focused on sexual risk among same-sex male couples.

CONCLUSIONS

Future research efforts should focus on the interrelationship of risk management strategies and relationship quality, social determinants of health and wellbeing, HIV testing, vulnerable populations, reproductive issues among same-sex couples, disclosure of serodiscordant status to social networks, dyadic studies, population-based studies, and interventions to support risk management within couples. Additional population-based studies and studies among marginalized groups would be helpful for targeting research and interventions to couples that are most in need. As HIV-positive partners are typically the link to services and research, innovative ways are needed for reaching out to HIV-negative partners. Our review suggests that significantly more research is needed to understand the social and behavioural contexts of HIV-serodiscordant relationships.

Reclaiming fertility awareness methods to inform timed intercourse for HIV serodiscordant couples attempting to conceive

INTRODUCTION

Increased life expectancy of HIV-positive individuals during recent years has drawn attention to their quality of life, which includes fulfillment of fertility desires. In particular, heterosexual HIV serodiscordant couples constitute a special group for whom the balance between desired pregnancy and the risk of viral transmission should be carefully considered and optimized. Although advanced assisted reproductive technologies are available, such treatments are expensive and are often unavailable. Moreover, standard viral load testing and antiretroviral therapy may not be accessible due to structural or individual barriers. To reduce the risk of HIV transmission, a lower cost alternative is timed condomless sex combined with other risk-reduction strategies. However, timed condomless sex requires specific knowledge of how to accurately predict the fertile window in a menstrual cycle. The aim of this study was to summarize inexpensive fertility awareness methods (FAMs) that predict the fertile window and may be useful for counselling HIV-positive couples on lower cost options to conceive.

METHODS

Original English-language research articles were identified by a detailed Medline and Embase search in July 2014. Relevant citations in the included articles were also retrieved.

RESULTS AND DISCUSSION

Calendar method, basal body temperature and cervicovaginal mucus secretions are the most accessible and sensitive FAMs, although poor specificity precludes their independent use in ovulation detection. In contrast, urinary luteinizing hormone testing is highly specific but less sensitive, and more expensive. To maximize the chance of conception per cycle, the likelihood of natural conception needs to be assessed with a basic fertility evaluation of both partners and a combination of FAMs should be offered. Adherence to other risk-reduction strategies should also be advised, and timely referral to reproductive medicine specialists is necessary when sub/infertility is suspected.

CONCLUSIONS

FAMs provide effective, economical and accessible options for HIV serodiscordant couples to conceive while minimizing unnecessary viral exposure. It is important for health care providers to initiate conversations about fertility desires in HIV-positive couples and to educate identified couples on safer conception strategies.

Fertility desires among HIV-infected men and women in Los Angeles County: client needs and provider perspectives

Combination antiretroviral therapy for persons living with HIV/AIDS (PLHA) has extended life expectancy, and enabled PLHA to live productive lives that can include having children. Despite calls to address childbearing for PLHA there has been limited attention to developing safe conception programs. This research sought to assess the childbearing desires of PLHA and the experiences of health care providers serving this population. Research entailed a brief cross-sectional client survey given to HIV-infected men and women over age 18 at two Los Angeles County clinics administered over an 8-week period. Focus group discussions were conducted with providers at each clinic site. Although 39% of the 93 clients surveyed reported a desire to have children, two-thirds of clients had not discussed their desires, or methods of safe conception, with providers. Providers reported challenges in providing safe conception services in resource poor settings where clients cannot afford assisted fertility services and in the absence of national, state, or county guidelines for safe conception. They noted complex and varied client circumstances and a critical need for provider training in safe conception. Guidelines that focus on safe conception and harm reduction strategies as well as the legal ramifications of counseling on these practices are needed. HIV providers need training and patients need educational tools and workshops informing them of the risks, challenges, and options available to them and their partners to safely conceive and bear an HIV-negative child.

The pregnancy decisions of HIV-positive women: the state of knowledge and way forward

Despite the growing number of women living with and affected by HIV, there is still insufficient attention to their pregnancy-related needs, rights, decisions and desires in research, policy and programs. We carried out a review of the literature to ascertain the current state of knowledge and highlight areas requiring further attention. We found that contraceptive options for pregnancy prevention by HIV-positive women are insufficient: condoms are not always available or acceptable, and other options are limited by affordability, availability or efficacy. Further, coerced sterilization of women living with HIV is widely reported. Information gaps persist in relation to effectiveness, safety and best practices regarding assisted reproductive technologies. Attention to neonatal outcomes generally outweighs attention to the health of women before, during and after pregnancy. Access to safe abortion and post-abortion care services, which are critical to women's ability to fulfill their sexual and reproductive rights, are often curtailed. There is inadequate attention to HIV-positive sex workers, injecting drug users and adolescents. The many challenges that women living with HIV encounter in their interactions with sexual and reproductive health services shape their pregnancy decisions. It is critical that HIV-positive women be more involved in the design and implementation of research, policies and programs related to their pregnancy-related needs and rights.