HIV incidence, pregnancy, and implementation outcomes from the Sakh'umndeni safer conception project in South Africa: a prospective cohort study

Uptake and Persistence of Safer Conception Strategies Among South African Women Planning for Pregnancy

Safer conception strategies can minimize HIV acquisition during periconception periods among women living in HIV-endemic areas. We examined uptake and predictors of persistent use of the same safer conception strategy among a cohort of HIV-uninfected South African women ages 18-35 years planning for pregnancy with a partner living with HIV or of unknown HIV-serostatus. The safer conception strategies we evaluated included oral PrEP, condomless sex limited to peak fertility, and waiting for a better time to have a child (until, for example, the risks of HIV acquisition are reduced and/or the individual is prepared to care for a child); persistence was defined as using the same safer conception strategy from the first visit through 9 months follow-up. Modified Poisson regression models were used to examine predictors of persistent use of the same strategy. The average age of 227 women in our cohort was 24.6 (range: 18.0, 35.7) years. In this cohort, 121 (74.2%) women reported persisting in the same strategy through 9 months. Employment and HIV knowledge were associated with the persistent use of any strategy. Our results highlight the need to provide safer conception services to women exposed to HIV during periconception periods. Findings also offer some insights into factors that might influence persistent use. Further research is needed to better understand how to involve male partners and how their involvement might influence women's consistent use of safer conception strategies during periconception periods.

A Differentiated HIV Pre-Exposure Prophylaxis Delivery Model for High-Risk Groups in Nanning City, South China: Findings from a Pilot Program

In China, pre-exposure prophylaxis (PrEP) uptake among men who have sex with men (MSM) and HIV-serodiscordant couples is low. We offered differentiated PrEP options tailored to MSM in a community-based organization (CBO) setting, and to HIV-serodiscordant couples attempting conception in a specialized HIV care clinic. The CBO facilitated PrEP by linkage with a telemedicine platform for virtual consultation; additional online follow-up on social media was conducted by peers. PrEP was taken properly in 88.7% of visits. Retention was 82.4% at Month 6. MSM having HIV-infected partners over the past 6 months were more likely to adhere to PrEP; ≥ 50 years old and daily oral PrEP were significant predictors for failing in retention. Five pregnancies were reported in the clinic. A peer-led and social media, telemedicine-assisted PrEP model within a CBO is a feasible approach to roll out PrEP among MSM. Integrated PrEP in specialized HIV clinics is appropriate for serodiscordant couples attempting conception.

"We chose PrEP because I wanted to be sure that this child my wife was going to conceive was indeed mine." Factors influencing the choice of safer conception methods and experiences with its use: a qualitative study among HIV sero-discordant couples in Zimbabwe

BACKGROUND

Safer conception services are needed to minimize HIV transmission among HIV sero-discordant couples desiring pregnancy. Few studies have evaluated the choices couples make when they are offered multiple safer conception methods or real-world method acceptability. This paper addresses an important knowledge gap regarding factors that influence the choice of safer conception methods, couples' actual experiences using safer conception methods, and why some couples switch safer conception methods.

METHODS

Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples who exited the SAFER study-a pilot safer conception study for HIV sero-discordant couples in Zimbabwe that offered couples a choice of ART with monthly viral load monitoring (ART/VL), oral PrEP, vaginal insemination, and semen washing. All couples in SAFER had used at least two safer conception methods.

RESULTS

We found that safer conception method choice often centered around a desire for intimacy, condomless sex, and certainty in the conception process, particularly for men. Method-related attributes such as familiarity, perceived ease of use, side effects, and perceived level of effectiveness in preventing HIV and achieving pregnancy influenced method choice, switching, and satisfaction. Concerns were expressed about each safer conception method and couples were willing to try different methods until they found method(s) that worked for them. The majority of participants reported having positive experiences using safer conception, especially those using ART/VL + PrEP, citing that they were able to attempt pregnancy for the first time with peace of mind and experienced joy and satisfaction from being able to achieve pregnancy safely.

CONCLUSIONS

The differences in method preferences and experiences voiced by participants in this study and in other studies from the region point to the importance of having a variety of safer conception options in the service delivery package and addressing concerns about paternity, intimacy, and method-related attributes to enable HIV sero-discordant couples to safely achieve their reproductive goals.

Modeled estimates of HIV-serodifferent couples in tuberculosis-affected households in four sub-Saharan African countries

Household-based tuberculosis (TB) contact evaluation may be an efficient strategy to reach people who could benefit from oral pre-exposure prophylaxis (PrEP) because of the epidemiological links between HIV and TB. This study estimated the number of HIV serodifferent couples in TB-affected households and potential HIV acquisitions averted through their PrEP use in 4 TB-HIV high-burden countries. We conducted a model-based analysis set in Ethiopia, Kenya, South Africa, and Uganda using parameters from population-based household surveys, systematic literature review and meta-analyses, and estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. We parameterized the nonlinear relationship between the proportion of serodifferent couples among people living with HIV and population-level HIV prevalence using Markov chain Monte Carlo methods. We integrated all parameters in a mathematical model and propagated uncertainty using a Monte Carlo approach. We estimated the HIV prevalence among adults aged 15-49 living in TB-affected households to be higher than in the general population in all 4 countries. The proportion of serodifferent couples among all couples in TB-affected households was also higher than in the general population (South Africa: 20.7% vs. 15.7%, Kenya: 15.7% vs. 5.7%, Uganda: 14.5% vs. 6.0%, Ethiopia: 4.1% vs. 0.8%). We estimated that up to 1,799 (95% UI: 1,256-2,341) HIV acquisitions in South Africa could be prevented annually by PrEP use in serodifferent couples in TB-affected households, 918 (95% UI: 409-1,450) in Kenya, 686 (95% UI: 505-871) in Uganda, and 408 (95% UI: 298-522) in Ethiopia. As couples in TB-affected households are more likely to be serodifferent than couples in the general population, offering PrEP during household TB contact evaluation may prevent a substantial number of HIV acquisitions.

Human rights and HIV: rhetoric or determinants?

International donors and UN agencies emphasise the importance of human rights as a key determinant of HIV vulnerability and of access, uptake and retention in HIV prevention and treatment services. Yet, the extent to which HIV researchers are incorporating rights into their research, the specific rights being examined and the frequency of research assessing rights-based approaches, is unknown.

METHODS

We examined all articles published in the five highest impact-factor HIV journals: (1) Lancet HIV; (2) AIDS and Behavior; (3) AIDS; (4) Journal of the International AIDS Society (JIAS); and (5) Journal of Acquired Immune Deficiency Syndromes (JAIDS), between 1 January 2017 and 31 December 2022, for reference to 'human right(s)' or 'right(s)'. We analysed articles to assess: (1) what populations were identified in relation to specific human rights concerns; (2) what specific rights were mentioned; (3) whether researchers cited specific legal frameworks; and (4) if and what types of rights-based interventions were examined.

RESULTS

Overall, 2.8% (n=224) of the 8080 articles reviewed included a mention of 'human right(s)' or 'right(s)'. Forty-two per cent of these (n=94) were original research articles. The most common key population discussed was men who have sex with men (33 articles), followed by sex workers (21 articles) and transgender people (14 articles). Of the 94 articles, 11 mentioned the right to health and nine referenced reproductive rights. Few articles identified a specific authority-whether in national, regional or international law-for the basis of the rights cited. Fourteen articles discussed rights-based interventions.

CONCLUSION

Despite global recognition of the importance of human rights to HIV outcomes, few HIV researchers publishing in the top five cited HIV journals include attention to human rights, or rights-based interventions, in their research. When rights are mentioned, it is often without specificity or recognition of the legal basis for human rights.

Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far

In 1989, one in four (25%) infants born to women living with HIV were infected; by the age of 2 years, there was 25% mortality among them due to HIV. These and other pieces of data prompted the development of interventions to offset vertical transmission, including the landmark Pediatric AIDS Clinical Trial Group Study (PACTG 076) in 1994. This study reported a 67.5% reduction in perinatal HIV transmission with prophylactic antenatal, intrapartum, and postnatal zidovudine. Numerous studies since then have provided compelling evidence to further optimize interventions, such that annual transmission rates of 0% are now reported by many health departments in the US and elimination has been validated in several countries around the world. Despite this success, the elimination of HIV's vertical transmission on the global scale remains a work in progress, limited by socioeconomic factors such as the prohibitive cost of antiretrovirals. Here, we review some of the key trials underpinning the development of guidelines in the US as well as globally, and discuss the evidence through a historic lens.

Preventing HIV and achieving pregnancy among HIV sero-different couples: Pilot study of a safer conception intervention in Zimbabwe

Safer conception services are needed to minimize HIV transmission among HIV sero-different couples desiring pregnancy. Few studies have evaluated the choices couples make when offered multiple safer conception methods or real-world method acceptability and effectiveness. We piloted a comprehensive safer conception program (Clintrials.gov identifier: NCT03049176) for HIV sero-different couples planning pregnancy in Zimbabwe to measure feasibility, method uptake, acceptability, pregnancy outcome, and HIV transmission. This study was not designed to compare rates of HIV transmission by safer conception method choice but rather to understand choices couples make when seeking to minimize risk of HIV transmission and maximize likelihood of pregnancy. Couples in this prospective, non-randomized study were given a choice of one or more currently available safer conception methods: antiretroviral therapy (ART) with monthly viral load (VL) monitoring for the HIV-positive partner (ART/VL), pre-exposure prophylaxis (PrEP) for the HIV-negative partner, vaginal insemination (VI) for couples with an HIV-positive woman, and semen washing (SW) for couples with an HIV-positive man. Couples were followed monthly for up to 12 months of pregnancy attempts, quarterly during pregnancy, and 12 weeks post-partum. At each visit, data on method use, urine for pregnancy testing, and blood for HIV antibody testing, or viral load if HIV-positive, were obtained. Infants born to HIV-positive women were tested for HIV at 6 and 12 weeks. Between March 2017 and June 2019, 46 individuals from 23 HIV sero-different partnerships were enrolled and followed. At enrollment, all couples chose ART/VL, and all couples chose at least one additional method; 74% chose PrEP, 36% chose SW, and 25% chose VI. During pre-pregnancy follow-up visits, three couples discontinued SW, and one couple discontinued VI; all four of these couples opted for ART/VL plus PrEP. Satisfaction with safer conception methods was high among those who chose ART/VL and PrEP. Twelve couples achieved pregnancy. There were no cases of HIV transmission to partners, and no infants tested positive for HIV. This safer conception program is feasible and acceptable, allowing sero-different couples to safely achieve pregnancy. Sero-different couples in Zimbabwe seek a combination of HIV prevention methods, particularly ART/VL plus PrEP. Trial Registration: Clintrials.gov, NCT03049176.

High PrEP uptake and objective longitudinal adherence among HIV-exposed women with personal or partner plans for pregnancy in rural Uganda: A cohort study

BACKGROUND

In Uganda, fertility rates and adult HIV prevalence are high, and many women conceive with partners living with HIV. Pre-exposure prophylaxis (PrEP) reduces HIV acquisition for women and, therefore, infants. We developed the Healthy Families-PrEP intervention to support PrEP use as part of HIV prevention during periconception and pregnancy periods. We conducted a longitudinal cohort study to evaluate oral PrEP use among women participating in the intervention.

METHODS AND FINDINGS

We enrolled HIV-negative women with plans for pregnancy with a partner living, or thought to be living, with HIV (2017 to 2020) to evaluate PrEP use among women participating in the Healthy Families-PrEP intervention. Quarterly study visits through 9 months included HIV and pregnancy testing and HIV prevention counseling. PrEP was provided in electronic pillboxes, providing the primary adherence measure ("high" adherence when pillbox was opened ≥80% of days). Enrollment questionnaires assessed factors associated with PrEP use. Plasma tenofovir (TFV) and intraerythrocytic TFV-diphosphate (TFV-DP) concentrations were determined quarterly for women who acquired HIV and a randomly selected subset of those who did not; concentrations TFV ≥40 ng/mL and TFV-DP ≥600 fmol/punch were categorized as "high." Women who became pregnant were initially exited from the cohort by design; from March 2019, women with incident pregnancy remained in the study with quarterly follow-up until pregnancy outcome. Primary outcomes included (1) PrEP uptake (proportion who initiated PrEP); and (2) PrEP adherence (proportion of days with pillbox openings during the first 3 months following PrEP initiation). We used univariable and multivariable-adjusted linear regression to evaluate baseline predictors selected based on our conceptual framework of mean adherence over 3 months. We also assessed mean monthly adherence over 9 months of follow-up and during pregnancy. We enrolled 131 women with mean age 28.7 years (95% CI: 27.8 to 29.5). Ninety-seven (74%) reported a partner with HIV and 79 (60%) reported condomless sex. Most women (N = 118; 90%) initiated PrEP. Mean electronic adherence during the 3 months following initiation was 87% (95% CI: 83%, 90%). No covariates were associated with 3-month pill-taking behavior. Concentrations of plasma TFV and TFV-DP were high among 66% and 47%, 56% and 41%, and 45% and 45% at months 3, 6, and 9, respectively. We observed 53 pregnancies among 131 women (1-year cumulative incidence 53% [95% CI: 43%, 62%]) and 1 HIV-seroconversion in a non-pregnant woman. Mean pillcap adherence for PrEP users with pregnancy follow-up (N = 17) was 98% (95% CI: 97%, 99%). Study design limitations include lack of a control group.

CONCLUSIONS

Women in Uganda with PrEP indications and planning for pregnancy chose to use PrEP. By electronic pillcap, most were able to sustain high adherence to daily oral PrEP prior to and during pregnancy. Differences in adherence measures highlight challenges with adherence assessment; serial measures of TFV-DP in whole blood suggest 41% to 47% of women took sufficient periconception PrEP to prevent HIV. These data suggest that women planning for and with pregnancy should be prioritized for PrEP implementation, particularly in settings with high fertility rates and generalized HIV epidemics. Future iterations of this work should compare the outcomes to current standard of care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03832530 https://clinicaltrials.gov/ct2/show/NCT03832530?term=lynn+matthews&cond=hiv&cntry=UG&draw=2&rank=1.

Oocytes could rearrange immunoglobulin production to survive over adverse environmental stimuli

Immunoglobulins are key humoral immune molecules produced and secreted by B lymphocytes at various stages of differentiation. No research has reported whether immunoglobulins are present in the non-proliferative female germ cells—oocytes—and whether they are functionally important for oocyte quality, self-protection, and survival. Herein, we found that IgG was present in the oocytes of immunodeficient mice; the IgG-VDJ regions were highly variable between different oocytes, and H3K27Ac bound and regulated the IgG promoter region. Next, IgG mRNA and protein levels increased in response to LPS, and this increment was mediated by CR2 on the oocyte membrane. Finally, we revealed three aspects of the functional relevance of oocyte IgG: first, oocytes could upregulate IgG to counteract the increased ROS level induced by CSF1; second, oocytes could upregulate IgG in response to injected virus ssRNA to maintain mitochondrial integrity; third, upon bacterial infection, oocytes could secrete IgG, subsequently encompassing the bacteria, thus increasing survival compared to somatic cells. This study reveals for the first time that the female germ cells, oocytes, can independently adjust intrinsic IgG production to survive in adverse environments.

The Fertility Status of the Married People Living with HIV/AIDS in China

In order to analyze the fertility status of the married people living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (PLHA) of reproductive age in China, a sample of married PLHAs aged 22-45 in China is selected by using a stratified cluster sampling method. All participants are face-to-face interviewed with a structured questionnaire. Among them, the fertility status and its influencing factors of 366 PLHAs are statistically analyzed. Experimental results show that married PLHA of reproductive age in China has a high proportion of having children. The fertility status and fertility intention of females are higher than that of males. The proportion of unwanted pregnancies after the HIV + diagnosis of females is high.

Sexual and Relationship Benefits of a Safer Conception Intervention Among Men with HIV Who Seek to Have Children with Serodifferent Partners in Uganda

Many men with HIV (MWH) in Uganda desire children, yet seldom receive reproductive counseling related to HIV care. Because men are under engaged in safer conception programming, they miss opportunities to reap the benefits of these programs. The objective of this sub-analysis was to explore the relationship and intimacy benefits of integrating safer conception counseling and strategies into HIV care, an emergent theme from exit interviews with men who participated in a pilot safer conception program and their partners. Twenty interviews were conducted with MWH who desired a child in the next year with an HIV-uninfected/status unknown female partner, and separate interviews were conducted with female partners (n = 20); of the 40 interviews, 28 were completed by both members of a couple. Interviews explored experiences participating in The Healthy Families program, which offered MWH safer conception counseling and access to specific strategies. Data were analyzed using thematic analysis. Three major subthemes or "pathways" to the relationship and intimacy benefits associated with participation in the program emerged: (1) improved dyadic communication; (2) joint decision-making and power equity in the context of reproduction; and (3) increased sexual and relational intimacy, driven by reduced fear of HIV transmission and relationship dissolution. These data suggest that the intervention not only helped couples realize their reproductive goals; it also improved relationship dynamics and facilitated intimacy, strengthening partnerships and reducing fears of separation. Directly addressing these benefits with MWH and their partners may increase engagement with HIV prevention strategies for conception.

Maternal PrEP Use in HIV-Uninfected Pregnant Women in South Africa: Role of Stigma in PrEP Initiation, Retention and Adherence

Pregnant women in sub-Saharan Africa are at high risk of HIV acquisition and require effective methods to prevent HIV. In a cohort of pregnant women offered Pre-exposure prophylaxis (PrEP), we evaluate the relationship between internalized and anticipated stigma and PrEP initiation at first antenatal visit, 3-month continuation and adherence using multivariable logistic regression. High internalized and anticipated PrEP stigma are associated with lower PrEP care initiation at first antenatal visit (aOR internalized stigma = 0.06; 95% CI = 0.03–0.11 and aOR anticipated stigma = 0.55; 95% CI = 0.31–1.00) compared to women with low reported stigma, after controlling for covariates. Women whose partners have not been tested for HIV or whose serostatus remains unknown have 1.6-times odds of PrEP retention at 3-months compared to women whose partners have been tested (aOR = 1.60; 95% CI = 1.02–2.52) after adjusting for covariates. PrEP counseling and maternal PrEP interventions must consider individual- and relational-level interventions to overcome anticipated PrEP stigma and other barriers to PrEP initiation and adherence.

Acceptability of an Intervention to Promote Viral Suppression and Serostatus Disclosure for Men Living with HIV in South Africa: Qualitative Findings

Men living with HIV (MLWH) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: (1) safer conception care acceptability is high but structural barriers challenge participation; (2) communication skills trainings helped overcome barriers to disclose serostatus; (3) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners.

Client and Provider Experiences in Uganda Suggest Demand for and Highlight the Importance of Addressing HIV Stigma and Gender Norms Within Safer Conception Care

Safer conception counseling supports HIV-serodifferent couples to meet reproductive goals while minimizing HIV transmission risk, but has not been integrated into routine HIV care. We piloted a novel safer conception program in an established public-sector HIV clinic in Uganda to inform future implementation. In-depth interviews and counseling observations explored experiences of program clients and healthcare providers to assess program acceptability, appropriateness, and feasibility. Fifteen index clients (8 women, 7 men), 10 pregnancy partners, and 10 providers completed interviews; 15 participants were living with HIV. Ten observations were conducted. We identified four emergent themes: (1) High demand for safer conception services integrated within routine HIV care, (2) Evolving messages of antiretroviral treatment as prevention contribute to confusion about HIV prevention options, (3) Gender and sexual relationship power inequities shape safer conception care, and (4) HIV-related stigma impacts safer conception care uptake. These findings confirm the need for safer conception care and suggest important implementation considerations.

Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana

BACKGROUND

A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake.

METHODS

We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables.

RESULTS

Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.

Attitudes Toward Pregnancy Among Women Enrolled in Prevention of Mother-to-Child Transmission of HIV (PMTCT) Services in Moshi, Tanzania

For pregnant women living with HIV (WLWH), feelings about pregnancy may influence their emotional well-being and health seeking behaviors. This study examined attitudes toward pregnancy and associated factors among women enrolled in prevention of mother-to-child transmission of HIV (PMTCT) services in Moshi, Tanzania. 200 pregnant WLWH were enrolled during their second or third trimester of pregnancy and completed a structured survey. Univariable and multivariable regression models examined factors associated with attitudes toward pregnancy, including demographics, interpersonal factors, and emotional well-being. Attitudes toward the current pregnancy were generally positive, with 87% of participants reporting feeling happy about being pregnant. In the final multivariable model, having higher levels of partner support, being newly diagnosed with HIV, and having fewer children were significantly associated with more positive attitudes toward their pregnancy. Findings point to a need for tailored psychosocial support services in PMTCT, as well as comprehensive reproductive health care for WLWH.

Demonstration and acceptability of a safer conception intervention for men with HIV in South Africa (Preprint)

Background

Many men with HIV (MWH) want to have children. HIV viral suppression minimizes sexual HIV transmission risks while allowing for conception and optimization of the health of men, their partners, and their infants.

Objective

This study developed and evaluated the feasibility and acceptability of an intervention to promote serostatus disclosure, antiretroviral therapy (ART) uptake and adherence, and viral suppression among MWH who want to have children in South Africa.

Methods

We developed a safer conception intervention (Sinikithemba Kwabesilisa or We give hope to men) to promote viral suppression via ART uptake and adherence, HIV serostatus disclosure, and other safer conception strategies for MWH in South Africa. Through 3 counseling and 2 booster sessions over 12 weeks, we offered education on safer conception strategies and aided participants in developing a safer conception plan. We recruited MWH (HIV diagnosis known for >1 month), not yet accessing ART or accessing ART for <3 months, in a stable partnership with an HIV-negative or unknown-serostatus woman, and wanting to have a child in the following year. We conducted an open pilot study to evaluate acceptability based on patient participation and exit interviews and feasibility based on recruitment and retention. In-depth exit interviews were conducted with men to explore intervention acceptability. Questionnaires collected at baseline and exit assessed disclosure outcomes; CD4 and HIV-RNA data were used to evaluate preliminary impacts on clinical outcomes of interest.

Results

Among 31 eligible men, 16 (52%) enrolled in the study with a median age of 29 (range 27-44) years and a median time-since-diagnosis of 7 months (range 1 month to 9 years). All identified as Black South African, with 56% (9/16) reporting secondary school completion and 44% (7/16) reporting full-time employment. Approximately 44% (7/16) of participants reported an HIV-negative (vs unknown-serostatus) partner. Approximately 88% (14/16) of men completed the 3 primary counseling sessions. In 11 exit interviews, men reported personal satisfaction with session content and structure while also suggesting that they would refer their peers to the program. They also described the perceived effectiveness of the intervention and self-efficacy to benefit. Although significance testing was not conducted, 81% (13/16) of men were taking ART at the exit, and 100% (13/13) of those on ART were virally suppressed at 12 weeks. Of the 16 men, 12 (75%) reported disclosure to pregnancy partners.

Conclusions

These preliminary data suggest that safer conception care is acceptable to men and has the potential to reduce HIV incidence among women and their children while supporting men’s health. Approximately half of the men who met the screening eligibility criteria were enrolled. Accordingly, refinement to optimize uptake is needed. Providing safer conception care and peer support at the community level may help reach men.

Trial Registration

ClinicalTrials.gov NCT03818984; https://clinicaltrials.gov/ct2/show/NCT03818984

International Registered Report Identifier (IRRID)

RR2-https://doi.org/10.1007/s10461-017-1719-4

Coping Mechanisms of Previously Diagnosed and New HIV-Discordant, Heterosexual Couples Enrolled in a Pilot HIV Self-Testing Intervention Trial in Central Uganda

Introduction: Learning that a couple has HIV-discordant results can create tensions in the relationship including separation. We explored the coping mechanisms of HIV-discordant, heterosexual couples enrolled in an HIV self-testing (HIVST) intervention trial in Central Uganda.

Materials and Methods: This qualitative study was nested within a pilot HIVST intervention trial targeting pregnant women and their male partners in central Uganda. In-depth interviews were conducted with 18 individuals from 13 HIV-discordant couples between July and September 2018; 18 months after the end of the main trial. Data were collected on the couples' initial reactions after learning about their HIV-discordant status, mechanisms adopted by couples to cope with HIV-discordance, and suggestions on how couples in similar situations can be supported. Interviews were transcribed verbatim and analysed manually following a thematic framework approach.

Findings: Of the 13 HIV-discordant couples, the female partner was HIV-positive (M–F+) in seven, while the male partner was HIV-positive (F–M+) in six. The mean (±SD) age of the participants was 32.6 (±6.4) years and participants had stayed together for an average of 5.5 (±3.6) years. Fourteen participants from nine couples already knew about their HIV-discordant status by the time they participated in the HIVST trial. After learning about their HIV-discordant status, most individuals (15) thought of abandoning their relationship; three (3) thought of committing suicide. To cope with HIV-discordance, some couples reported that they sought professional counselling support from healthcare providers, and this was particularly true for couples that were already aware of their HIV-discordant status by the time they participated in the HIVST trial. However, new couples that learnt about their HIV-discordant status after participating in the trial reported that they sought psycho-social support from friends or relatives. In the majority of cases, couples reported that they reduced the frequency of sex or abstained from sex. Some couples temporarily separated from their partners, while a few others resorted to using condoms to reduce HIV infection risk.

Conclusion: Couples used a variety of approaches to cope with HIV-discordance. Study findings underscore the importance of ongoing professional counselling and psycho-social support in helping couples to cope with HIV-discordance.

HIV risk and pre-exposure prophylaxis interest among women seeking post-abortion care in Kenya: a cross-sectional study

INTRODUCTION

Post-abortion clinics located in regions with high HIV burden may ideal locations to integrate counselling and delivery of HIV pre-exposure prophylaxis (PrEP), aligning with normative goals for integrated delivery of HIV and reproductive health care. The objective of this study was to gauge the degree to which Kenyan women seeking care for a pregnancy loss, including induced abortion, are at risk for HIV and whether women would welcome an introduction to PrEP prior to discharge from post-abortion care.

METHODS

We conducted a mixed-methods study from August 2019 to February 2020 with women ages 15 to 30 recruited sequentially as they were accessing post-abortion care at public and private facilities in Thika and Kisumu, Kenya. Data collection was through a cross-sectional survey and laboratory testing for common sexually transmitted infections (N = 200), and in-depth interviews (N = 30). Descriptive statistics summarize PrEP knowledge and referrals and a multivariable log-link binomial model estimated correlates of receiving a referral for PrEP. Qualitative data were analysed using inductive and deductive approaches.

RESULTS

Among 200 HIV-negative women (median age 21.0, interquartile range 19.0 to 22.0), the prevalence of Chlamydia trachomatis was 18.2% and Neisseria gonorrhoeae was 2.0%. Half of the women scored ≥5 on a validated tool that would correspond to an expected HIV incidence of 9.5% per year. Approximately half (55.8%) of women were familiar with PrEP prior to the study and 33.3% received a referral from study staff to a clinic offering PrEP. In qualitative interviews, women expressed interest in accessing PrEP from the gynaecology ward that provided post-abortion care but they preferred alternative locations for PrEP refills.

CONCLUSIONS

Kenyan women accessing post-abortion care have substantial HIV risk and were favourable about the idea of receiving support to initiate PrEP as part of care offered during post-abortion care. These settings can be integrated into national PrEP programmes as locations providing PrEP referrals and initiation.

"Our Choice" improves use of safer conception methods among HIV serodiscordant couples in Uganda: a cluster randomized controlled trial evaluating two implementation approaches

Background

Safer conception counseling (SCC) to promote the use of safer conception methods (SCM) is not yet part of routine family planning or HIV care. Guidelines for the use of SCM have been published, but to date there are no published controlled evaluations of SCC. Furthermore, it is unknown whether standard methods commonly used in resource constrained settings to integrate new services would be sufficient, or if enhanced training and supervision would result in a more efficacious approach to implementing SCC.

Methods

In a hybrid, cluster randomized controlled trial, six HIV clinics were randomly assigned to implement the SCC intervention Our Choice using either a high (SCC1) or low intensity (SCC2) approach (differentiated by amount of training and supervision), or existing family planning services (usual care). Three hundred eighty-nine HIV clients considering childbearing with an HIV-negative partner enrolled. The primary outcome was self-reported use of appropriate reproductive method (SCM if trying to conceive; modern contraceptives if not) over 12 months or until pregnancy.

Results

The combined intervention groups used appropriate reproductive methods more than usual care [20.8% vs. 6.9%; adjusted OR (95% CI)=10.63 (2.79, 40.49)], and SCC1 reported a higher rate than SCC2 [27.1% vs. 14.6%; OR (95% CI)=4.50 (1.44, 14.01)]. Among those trying to conceive, the intervention arms reported greater accurate use of SCM compared to usual care [24.1% vs. 0%; OR (95% CI)=91.84 (4.94, 1709.0)], and SCC1 performed better than SCC2 [34.6% vs. 11.5%; OR (95% CI)=6.43 (1.90, 21.73)]. The arms did not vary on modern contraception use among those not trying to conceive. A cost of $631 per person was estimated to obtain accurate use of SCM in SCC1, compared to $1014 in SCC2.

Conclusions

More intensive provider training and more frequent supervision leads to greater adoption of complex SCM behaviors and is more cost-effective than the standard low intensity implementation approach.

Trial registration

Clinicaltrials.gov, NCT03167879; date registered May 23, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01109-z.

Use of fertility awareness methods as a component of safer conception for women in HIV-serodifferent relationships in Kenya

Background

For couples affected by HIV, and serodifferent couples in particular, pregnancy desire is often juxtaposed against the risk of HIV transmission between the couple and the potential neonate leading to thinking about measures to minimize risk of HIV transmission. We assess the use of fertility awareness methods [FAM] and evaluate the drivers of alignment between indicators of fertility and sexual behavior among HIV-serodifferent couples desiring pregnancy.

Methods

HIV-serodifferent couples from Thika, Kenya were enrolled into an open-label pilot evaluation of safer conception strategies. Women responded to daily 7-item short message service [SMS] surveys on FAM and sexual activity. Menstrual cycles were categorized as having condomless sex aligned, not aligned, or partially aligned to the predicted peak fertility. We used binomial logit models with generalized estimating equations to assess alignment between condomless sex during peak fertility days and FAM results. We used Cox proportional hazards to compare pregnancy incidence among months with sex and peak fertility aligned and mis-aligned.

Results

A total of 6929 SMS surveys across 252 menstrual cycles of 65 women were included. Reporting “sticky” cervical mucus (adjusted odds ratio [aOR]: 2.25, 95% confidence interval [95% CI]: 1.30, 3.90) and positive ovulation prediction kit [OPK] result (aOR: 2.07, 95% CI: 1.11, 3.86) were associated with increased likelihood of alignment of condomless sex during peak fertility. Pregnancy incidence was statistically similar among periods with sex aligned and not aligned with peak fertility.

Conclusions

Among women engaged in a comprehensive safer conception program, a moderate percentage of women aligned condomless sex and predicted peak fertility days at least once. While FAM, particularly cervical mucus and OPK, are an inexpensive option for couples to consider using as a component of their safer conception strategies, antiretroviral-based strategies remain important to minimize risk.

"It really proves to us that we are still valuable": Qualitative research to inform a safer conception intervention for men living with HIV in South Africa

Objective

Many men living with HIV want to have children. Opportunities to reduce periconception HIV transmission include antiretroviral therapy as prevention, pre-exposure prophylaxis, limiting condomless sex to peak fertility, and sperm processing. Whether men have knowledge of or want to adopt these strategies remains unknown.

Methods

We conducted focus group discussions (FGDs) with men accessing HIV care in South Africa in 2014 to inform a safer conception intervention for men. Eligible men were 25–45 years old, living with HIV, not yet accessing treatment, and wanting to have a child with an HIV-negative or unknown serostatus female partner (referred to as the “desired pregnancy partner”). FGDs explored motivations for having a healthy baby, feasibility of a clinic-based safer conception intervention, and acceptability of safer conception strategies. Data were analyzed using thematic analysis.

Results

Twelve participants from three FGDs had a median age of 37 (range 23–45) years, reported a median of 2 (range 1–4) sexual partners, and 1 (range 1–3) desired pregnancy partner(s). A third (N = 4) had disclosed HIV-serostatus to the pregnancy partner. Emergent themes included opportunities for and challenges to engaging men in safer conception services. Opportunities included enthusiasm for a clinic-based safer conception intervention and acceptance of some safer conception strategies. Challenges included poor understanding of safer conception strategies, unfamiliarity with risk reduction [versus “safe” (condoms) and “unsafe” (condomless) sex], mixed acceptability of safer conception strategies, and concerns about disclosing HIV-serostatus to a partner.

Conclusions

Men living with HIV expressed interest in safer conception and willingness to attend clinic programs. Imprecise prevention counseling messages make it difficult for men to conceptualize risk reduction. Effective safer conception programs should embrace clear language, e.g. undetectable = untransmittable (U = U), and support multiple approaches to serostatus disclosure to pregnancy partners.

"What if they are pre-conception? What should we do?": Knowledge, practices, and preferences for safer conception among women living with HIV and healthcare providers in Gaborone, Botswana

Safer conception interventions that address HIV care, treatment, and prevention for HIV-affected couples are increasingly available in sub-Saharan Africa. Botswana, an HIV endemic country, is yet to offer formal safer conception services although universal test-and-treat approaches mean that increasing numbers of young, sexually active people living with HIV will start treatment and likely desire childbearing. In order to advance the safer conception discussion in Botswana, it is necessary to understand the current safer conception knowledge, practices, and preferences of healthcare providers and women living with HIV (WLHIV). We conducted qualitative in-depth interviews with 10 HIV healthcare providers and 10 WLHIV in Gaborone. Interviews were analyzed using a phenomenological approach. Safer conception knowledge was limited and safer conception discussions were rare. Healthcare provider and WLHIV preferences were at odds, with providers preferring WLHIV to initiate safer conception discussions, and WLHIV desiring providers to initiate safer conception discussions. Quotes from women and providers highlight deeper issues about power dynamics, concerns about stigma among women, and provider fears about promoting pregnancy. Providers emphasized the need for guidelines and training in order to improve the provision of safer conception counseling. These findings point to areas where safer conception in Botswana can be improved. Both WLHIV and providers would benefit from having information about a range of safer conception methods and approaches. In addition, since WLHIV felt hesitant about initiating safer conception conversations and feared stigma, and because putting the onus for starting safer conception discussions on women is a reversal of normal roles and power structures, providers must take the lead and routinely initiate fertility desire and safer conception discussions. Assisting healthcare providers with clear safer conception guidelines and training would improve the provision of accurate safer conception counseling and facilitate reproductive choice.

Reaching the second 90: the strategies for linkage to care and antiretroviral therapy initiation

We present recent literature describing interventions for linkage to HIV care in the era of Universal Test and Treat (UTT) policies. We also provide information for ongoing studies of linkage to care strategies registered with ClinicalTrials.gov.

Characterizing the role of intersecting stigmas and sustained inequities in driving HIV syndemics across low-to-middle-income settings

PURPOSE OF REVIEW

In 2020, key populations around the world still have disproportionate risks for HIV acquisition and experiencing HIV-related syndemics. This review presents current data around HIV-related syndemics among key populations globally, and on the role of intersecting stigmas in producing these syndemics in low-to-middle-income settings.

RECENT FINDINGS

Sex workers, sexual and gender minorities, prisoners, and people who use drugs experience high burdens of tuberculosis, sexually transmitted infections, viral hepatitis, and violence linked to heightened HIV-related risks or acquisition. Adverse sexual, reproductive, and mental health outcomes are also common and similarly amplify HIV acquisition and transmission risks, highlighting the need for psychosocial and reproductive health services for key populations.

SUMMARY

Achieving the promise of biomedical interventions to support HIV care and prevention requires action towards addressing syndemics of HIV, and the stigmas that reproduce them, among those most marginalized globally.

'I'm waiting for that': Interest in the use of PrEP for safer conception in Botswana

Safe and effective low-cost safer conception (SC) methods are increasingly available and being integrated into national guidelines in sub-Saharan African contexts. Sero-different couples of childbearing age can benefit from such services and the routine provision of SC counselling. Pre-exposure prophylaxis (PrEP) to prevent HIV acquisition to uninfected partners can reduce the chances of HIV transmission when trying to achieve pregnancy. Botswana has a strong commitment to reducing new HIV infections but PrEP is not yet widely available and little guidance has been offered on counselling sero-different couples. We conducted qualitative in-depth interviews in Gaborone, Botswana with 10 HIV healthcare providers and 10 women living with HIV of childbearing age because they act as a key conduit for reaching sero-different partners with information about PrEP. We examined knowledge and attitudes towards PrEP to assess the viability and develop a deeper understanding of this SC option. Interviews were analysed using an interpretive phenomenological approach. Three themes emerged: (1) awareness of PrEP is limited, (2) providers and women overwhelmingly showed interest in PrEP and (3) women living with HIV and providers have concerns about PrEP use. With the correct support, PrEP could be a useful SC option for sero-different couples in Botswana and other sub-Saharan contexts.