"I may not say we really have a method, it is gambling work": knowledge and acceptability of safer conception methods among providers and HIV clients in Uganda

Scoping review of qualitative studies on family planning in Uganda

Family planning (FP) is an essential component of public health programs and significantly impacts maternal and child health outcomes. In Uganda, there is a need for a comprehensive review of the existing literature on FP to inform future research and programmatic efforts. This scoping review aims to identify factors shaping the use of FP in Uganda. We conducted a systematic search of eight scholarly databases, for qualitative studies on FP in Uganda. We screened the titles and abstracts of identified articles published between 2002-2023 and assessed their eligibility based on predefined criteria. We extracted data from the 71 eligible studies and synthesized the findings using thematic analysis and the Ecological Systems Theory (EST) individual, interpersonal, community, institutional, and policy-level determinants. Findings reveal the interplay of factors at different socio-ecological levels influencing family planning decisions. At the individual level, the most common determinants related to the EST were knowledge and attitudes of FP. Interpersonal dynamics, including partner communication and social support networks, played pivotal roles. Community-level factors, such as cultural norms and accessibility of services, significantly influenced family planning practices. Institutional and policy-level factors, particularly a healthcare system's quality and policies, also shaped use. Other themes included the intersection of HIV/AIDS on FP practice and Ugandan views of comprehensive abortion care. This scoping review underscores the intricate socio-ecological fabric shaping FP in Uganda. The findings highlight the need for targeted interventions to increase knowledge and awareness of FP, improve access to services, and address social and cultural norms that discourage contraceptive use. Policymakers and program implementers should also consider gender dynamics and power imbalances in FP programs to ensure they are equitable and effective.

Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda

Linkage to care for newly diagnosed human immunodeficiency virus (HIV) patients is important to ensure that patients have good access to care. However, there is little information about factors influencing linkage to care for HIV patients. We aimed to identify existing measures in place that promote linkage to care and to explore facilitators and barriers to linkage to care for clients diagnosed with HIV/acquired immune deficiency syndrome at a rural health center in Uganda. This descriptive qualitative study enrolled 33 purposively selected participants who included expert clients, linkage facilitators, heads of families with people living with HIV, and health workers. Data were collected using in-depth interviews that were audio-recorded, transcribed, and translated. The data were manually analyzed to generate themes. The following four themes were generated: 1) availability of services that include counseling, testing, treatment, follow-up, referral, outreach activities, and support systems. 2) Barriers to linkage to care were at the individual, health facility, and community levels. Individual-level barriers were socioeconomic status, high transport costs, fear of adverse drug effects, fear of broken relationships, and denial of positive results or treatment, while health facility barriers were reported to be long waiting time, negative staff attitude, and drug stock outs. Community barriers were mostly due to stigma experienced by HIV clients, resulting in discrimination by community members. 3) Facilitators to linkage to care were positive staff attitudes, access to information, fear of death, and support from others. 4) Suggestions for improving service delivery were shortening waiting time, integrating HIV services, increasing staff numbers, and intensifying outreaches. Our findings highlight the importance of stakeholder involvement in linkage to care. Access and linkage to care are positively and negatively influenced at the individual, community, and health facility levels. However, integration of HIV services and intensifying outreaches are key to improving linkage to care.

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.

"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.

"I did not know about all these": Perceptions regarding safer conception methods by women living with HIV in Gaborone, Botswana

Various safer conception methods to limit HIV transmission risks can be offered in resource-constrained settings. However, implementation of safer conception services remains limited in many countries, including Botswana. Understanding perceptions about safer conception methods and the benefits and challenges to use can help with the development of policies, interventions, and service delivery models. Forty-five women living with HIV in the greater Gaborone, Botswana area participated in focus group discussions. Themes were analyzed using interpretive phenomenology. Despite low knowledge of specific safer conception methods that can be used to prevent transmission of HIV when trying to achieve pregnancy, there was noted interest in pre-exposure prophylaxis and vaginal insemination. Challenges to greater uptake were noted including a lack of knowledge about a range of SC methods, limited partner support and communication, provider stigma, health systems barriers, current policies, and the cultural acceptability of methods. Interventions will need to address these challenges and be responsive to the needs and reflect the realities of WLHIV who desire pregnancy in order for safer conception uptake to become a common practice.

Discussing Reproductive Plans with Healthcare Providers by Sexually Active Women Living with HIV in Western Ethiopia

Discussing reproductive plans with healthcare providers by women living with HIV (WLHIV) can assist in promoting safe reproductive health practices, but little research has been undertaken in this area. A cross-sectional survey was conducted in western Ethiopia in 2018 among 475 sexually active WLHIV. One hundred and twenty seven (26.8%) participants reported becoming pregnant in the last 5 years after being aware of their HIV-positive status; 33.6% reported their intention to have children in the future, and 26.9% were ambivalent about having children. WLHIV who reported general and personalized discussions of reproductive plans with healthcare providers were 30.7% and 16.8%, respectively. Unmarried sexually active women and WLHIV accessing health centers for antiretroviral therapy (ART) were less likely to report both general and personalized discussions than married women and women who accessed ART through hospitals, respectively. WLHIV are both having and intending to have children, highlighting discussions with healthcare providers can deliver support that reduces the risk of vertical and horizontal HIV transmission.

Health workers' knowledge of safer conception and attitudes toward reproductive rights of HIV-infected couples in Kano, Nigeria

BACKGROUND

The restriction of reproductive rights of HIV-positive couples in low-resource settings could be related to the attitudes and skills of health workers. We assessed health workers' knowledge of safer conception and their attitudes toward the reproductive rights of HIV-positive couples in a tertiary hospital in Nigeria.

METHODS

A cross-section of health workers (n=294) was interviewed using structured questionnaires. Knowledge and attitude scores were analyzed. Logistic regression was employed to generate adjusted odds ratios (AORs) for predictors of attitude.

RESULTS

Safer conception methods mentioned by respondents included timed unprotected intercourse with (27.9%) and without antiretroviral pre-exposure prophylaxis (37.4%), in vitro fertilization plus intracytoplasmic sperm injection (26.5%), and sperm washing and intrauterine insemination (24.8%). The majority (94.2%) of health workers acknowledged the reproductive rights of HIV-infected persons, although (64.6%) strongly felt that HIV-infected couples should have fewer children. Health workers reported always/nearly always counseling their patients on HIV transmission risks (64.1%) and safer conception (59.2% and 48.3% for females and males, respectively) (p<0.05). Among health workers, being older (30-39 vs <30 y) (AOR=1.33, 95% CI=1.13-2.47), married (AOR=2.15, 95% CI=1.17-5.58) and having a larger HIV-positive daily caseload (20-49 vs <20) (AOR=1.98, 95% CI=1.07-3.64) predicted positive attitude towards reproductive rights of HIV-affected couples.

CONCLUSIONS

Health workers had limited knowledge of safer conception methods, but were supportive of the reproductive rights of HIV-positive couples. Health workers in Nigeria require training to effectively counsel couples on their reproductive rights, risks and options.

Predictors of Safer Conception Practices Among HIV-Infected Women in Northern Nigeria

Background: Persons living with HIV often face discrimination in safe sex and reproductive choices, especially in lowresource settings. This study assessed fertility desires and intentions, risk perception and correlates of ever use of at least one safer conception method among HIV-infected women attending a tertiary health facility in Kano, Nigeria.

Methods: Structured questionnaires were administered to a cross section of 328 of 427 eligible HIV-infected women. Fertility desires and intentions, risk perception and safer conception practice were analyzed. Logistic regression was employed to assess for predictors.

Results: Of the 328 respondents, 150 respondents (45.7%) wanted more children. The proportions of respondents aware of their transmission risk during pregnancy, delivery, and breastfeeding were 69.5%, 75.3%, and 78.9%, respectively. Further, 68.9% of respondents were aware of the prospects of bearing HIV-negative children without infecting their partners. About 64.8% of women were aware of at least one safer conception method. Safer conception methods everused by the participants include: antiretroviral therapy (ART) (36.7%), timed unprotected intercourse with (10.9%), and without pre-exposure prophylaxis (PrEP) (17.2%), intravaginal insemination (7.3%) and intrauterine insemination (4.7%). Safer conception practice was predicted by marital status (married versus single, adjusted odds ratio [AOR]=1.50, 95% CI =1.10-3.55), parity (2-4 versus 0, AOR=12.1, 95% CI=3.7-39.8), occupation (civil servants versus traders, AOR=0.37, 95% CI=0.16-0.86), husband’s serostatus (seroconcordant versus serodiscordant) (AOR=1.51, 95% CI=1.13-4.64), couple contraceptive use (users versus non-users) (AOR=1.62, 95% CI=1.16-5.83) and transmission risk perception (high risk versus low/no risk) (AOR=2.14, 95% CI=1.18-3.90).

Conclusion: We found high levels of fertility desires and intentions and moderate risk perception among a cohort of HIV-infected women in urban Kano, Nigeria. The use of safer conception practices was not common. Our findings underscore the need for healthcare provider capacity building to enhance safer conception counseling and service delivery.

Perceptions of pregnancy occurring among HIV-serodiscordant couples in Kenya

BACKGROUND

Among HIV serodiscordant couples, most conception involves condomless sex and may confer a period with increased HIV transmission risk if HIV viral load is not suppressed and other precautions are not used. Safer conception strategies enable HIV serodiscordant couples to attain their pregnancy goals while markedly reducing this risk. We explored the perceptions and beliefs held by HIV serodiscordant couples and health care providers concerning pregnancy among HIV serodiscordant couples in Kenya and gathered their thoughts about how these might influence use of safer conception methods.

METHODS

We conducted 20 Key Informant Interviews (KIIs) with health care providers offering safer conception counseling and 21 In-Depth Interviews (IDIs) and 4 Focus Group Discussions (FGDs) with members of HIV serodiscordant couples with immediate pregnancy goals in Thika, Kenya. Data were analyzed using an inductive approach that identified two emergent themes: perceptions towards pregnancy among HIV serodiscordant couples and access to safer conception services.

RESULTS

The perceptions held by the community towards couples in HIV serodiscordant relationships having children were largely negative. The participants were aware of the increased HIV transmission risk to the HIV uninfected partners while trying to become pregnant. In the community, having biological children was cherished yet the majority of the couples shied away from accessing safer conception services offered at health facilities due to stigma and lack of knowledge of the existence of such services. Some providers had limited knowledge on safer conception strategies and services and consequently discouraged HIV serodiscordant couples from natural conception.

CONCLUSIONS

Negative perceptions towards HIV serodiscordant couples becoming pregnant has hindered access to safer conception services. Therefore, there is need to create a supportive environment for HIV serodiscordant couples with fertility intentions that normalizes their desire to have children and informs the community about the availability of safer conception services.

Knowledge and correlates of use of safer conception methods among HIV-infected women attending HIV care in Uganda

BACKGROUND

Many people living with HIV would like to have children but family planning (FP) services often focus on only contraception. Availability of safer conception services is still very low in most low income countries. In this study we assessed the knowledge and use of safer conception methods (SCM) among HIV infected women in HIV care in Uganda to inform integration of safer conception in existing FP services.

METHODS

Data were accrued from a nationally representative cross-sectional survey of 5198 HIV+ women aged 15-49 years from 245 HIV clinics in Uganda. Knowledge and use of safer conception methods and associated factors were determined. The measure of association was prevalence ratio (PR) with corresponding 95% confidence intervals, obtained using a modified Poisson regression via generalized linear models. All the analyses were conducted using STATA version 12.0.

RESULTS

Overall knowledge of any safer conception method was 74.1% (3852/5198). However only 13.2% knew 3 to 4 methods, 18.9% knew only 2 methods and 42% knew only one method. Knowledge of specific SCM was highest for timed unprotected intercourse (TUI) at 39% (n = 2027) followed by manual self-insemination (MSI) at 34.8% (n = 1809), and pre-exposure prophylaxis (PrEP) at 24.8% (n = 1289). Knowledge of SCM was higher in the Eastern region (84.8%, P < 0.001), among women in HIV-discordant relationships (76.7%, p < 0.017), and those on ART (74.5%, p < 0.034). Overall, 1796 (34.6%) women were pregnant or reported a birth in the past 2 years-overall use of SCM in this group was 11.6% (209/1796). The odds of use of SCM were significantly lower in Kampala [adj. PR = 0.489(0.314, 0.764)] or Eastern region [adj.PR = 0.244; (0.147, 0.405)] compared to Northern region. Higher odds of SCM use were associated with HIV status disclosure to partner [adj.PR = 2.613(1.308, 5.221)] and sero-discordant compared to HIV+ concordant relationship [adj.PR = 1.637(1.236, 2.168)]. Pre-existing knowledge of any one SCM did not influence SCM use.

CONCLUSIONS

Knowledge and use of SCM among HIV+ women in care is low. Efforts to improve HIV status disclosure, integration of safer conception into FP and HIV services and regional efforts to promote sensitization and access to safer conception can help to increase uptake of safer conception methods.

Clients' experiences utilizing a safer conception service for HIV affected individuals: implications for differentiated care service delivery models

Background

Safer conception services promote the reproductive health and rights of families, while minimizing HIV transmission risks between partners trying to conceive, as well vertical transmission risks. Implementation data, including clients’ experiences utilizing safer conception services in sub-Saharan Africa are limited.

Methods

Hillbrow Community Health Centre began offering safer conception services for individuals and couples affected by HIV in Johannesburg, South Africa in June 2015. A stratified sub-sample of safer conception clients were consecutively recruited from April 2016–August 2017 for a cross-sectional interview assessing clients’ perceptions of service acceptability and value, as well as perceived safer conception knowledge and self-efficacy. Visual analog scales from 0 to 100 were used to measure clients’ experiences; scores were classified as low, moderate and high acceptance/value/knowledge/self-efficacy if they were < 50, 50–79 and ≥ 80 respectively. Comparisons of scores were made across safer conception visits attended.

Results

Among 692 clients utilizing safer conception services, 120 (17%) were sampled for the process evaluation; sub-sample participant characteristics were similar to the overall cohort. Clients gave a mean score of ≥90-points for each question assessing service acceptability and 96% (114/119) indicated a high perceived value (scores ≥80) for regular safer conception attendance until conception. Fifty-eight percent (n = 70) of clients reported learning something new during the visit completed the day of the survey, though acquisition of new information tended to decrease as visits increased (p = 0.09). In terms of safer conception strategies, 80% of clients reported high levels of knowledge on the impact of antiretroviral treatment (ART) and viral suppression on HIV transmission, 67% reported high levels of knowledge of the importance of STI screening and 56% regarding limiting condomless sex to days of peak fertility; 34% in sero-different relationships reported high pre-exposure prophylaxis (PrEP) knowledge. Self-efficacy varied by safer conception methods and was similar across study visits.

Conclusions

Clients perceived high value from their safer conception visits and preferred regular attendance until conception, however we observed a plateau in knowledge and self-efficacy across subsequent visits after initially attending safer conception care. More intensive services may be appropriate for certain clients based on clinical circumstances, but many couples may potentially receive a ‘lighter touch’ approach while still minimizing HIV transmission risks.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0718-5) contains supplementary material, which is available to authorized users.

Changes in Providers' Self-Efficacy and Intentions to Provide Safer Conception Counseling Over 24 Months

High rates of fertility desires, childbearing and serodiscordant partnerships among people living with HIV (PLHIV) in Uganda underscore the need to promote use of safer conception methods (SCM). Effective SCM exist but few PLHIV benefit from provider-led safer conception counseling (SCC) and comprehensive national SCC guidelines are still lacking. Providers' self-efficacy, intentions and attitudes for SCC impact provision and should inform development of services, but there are no longitudinal studies that assess these important constructs. This study reports on changes in providers' knowledge, attitudes, motivation and confidence to provide SCC among a 24-month observational cohort of Ugandan HIV providers. Compared to baseline, providers evidenced increased awareness of SCM, perceived greater value in providing SCC, saw all SCM but sperm washing as likely to be acceptable to clients, reported consistently high interest in and peer support for providing SCC, and perceived fewer barriers at the 24-month follow-up. Providers' intentions for providing SCC stayed consistently high for all SCM except manual self-insemination which decreased at 24 months. Self-efficacy for providing SCC increased from baseline with the greatest improvement in providers' confidence in advising serodiscordant couples where the man is HIV-infected. Providers consistently cite the lack of established guidelines, training, and their own reluctance to broach the issue with clients as significant barriers to providing SCC. Despite providers being more interested and open to providing SCC than ever, integration of SCC into standard HIV services has not happened. Concerted efforts are needed to address remaining barriers by establishing national SCC guidelines and implementing quality provider training.

A Systematic Review of the Current Status of Safer Conception Strategies for HIV Affected Heterosexual Couples in Sub-Saharan Africa

We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception interventions. Following PRISMA guidelines, we searched fifteen electronic databases using the following inclusion criteria: SCS research in HIV-affected couples; published after 2007; in sub-Saharan Africa; primary research; peer-reviewed; and addressed a primary topic of interest (SCS availability, feasibility, and acceptability, and/or education and promotion). Researchers independently reviewed each study for eligibility using a standardized tool. We categorize studies by their topic area. We identified 41 studies (26 qualitative and 15 quantitative) that met inclusion criteria. Reviewed SCSs included: antiretroviral therapy (ART), pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC). SCS were largely unavailable outside of research settings, except for general availability (i.e., not specifically for safer conception) of ART and VMMC. SCS acceptability was impacted by low client and provider knowledge about safer conception services, stigma around HIV-affected couples wanting children, and difficulty with HIV disclosure in HIV-affected couples. Couples expressed desire to learn more about SCS; however, provider training, patient education, SCS promotions, and integration of reproductive health and HIV services remain limited. Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge. SCS are not yet widely available to HIV-affected African couples. Successful implementation of SCS requires that providers receive training on effective SCS and provide couple-based safer conception counseling to improve disclosure and communication around fertility intentions and reproductive health.

Study protocol of "Our Choice": a randomized controlled trial of the integration of safer conception counseling to transform HIV family planning services in Uganda

BACKGROUND

About 40% of HIV-positive women in sub-Saharan Africa become pregnant post-diagnosis. Despite about half of their pregnancies being planned, safer conception methods (SCM) are underutilized among serodiscordant couples, partially due to the fact that safer conception counseling (SCC) has not been integrated into routine HIV family planning (FP) services.

METHODS

Our Choice is a comprehensive FP intervention that promotes unbiased childbearing consultations to ensure clients receive SCC or contraception services to achieve their desired reproductive goals. The intervention is theoretically grounded and has demonstrated preliminarily feasibility and acceptance through pilot testing. This three-arm cluster randomized controlled trial compares two implementation strategies for integrating Our Choice into routine FP services vs. usual care. Six sites in Uganda will be randomized to receive either (1) Our Choice intervention with enhanced training and supervision provided by study staff (SCC1), (2) Our Choice intervention implemented by the Ministry of Health's standard approach to disseminating new services (SCC2), or (3) existing FP services (usual care). Our Choice and usual care FP services will be implemented simultaneously over a 30-month period. Sixty clients in serodiscordant relationships who express childbearing desires will be enrolled by a study coordinator at each site (n = 360) and followed for 12 months or post-pregnancy (once, if applicable). Analysis will compare intervention arms (SCC1 and SCC2) to usual care and then to each other (SCC1 vs. SCC2) on the primary outcome of correct use of either SCM (if trying to conceive) or dual contraception (if pregnancy is not desired). Secondary outcomes (i.e., pregnancy, use of prevention of mother-to-child transmission services, condom use, and partner seroconversion) and cost-effectiveness will also be examined.

DISCUSSION

Findings will provide critical information about the success of implementation models of varying intensity for integrating SCC into FP, thereby informing policy and resource allocation within and beyond Uganda.

TRIAL REGISTRATION

NCT03167879 ClinicalTrials.gov, Registered 30 May, 2017.

Consensus statement: Supporting Safer Conception and Pregnancy For Men And Women Living with and Affected by HIV

Safer conception interventions reduce HIV incidence while supporting the reproductive goals of people living with or affected by HIV. We developed a consensus statement to address demand, summarize science, identify information gaps, outline research and policy priorities, and advocate for safer conception services. This statement emerged from a process incorporating consultation from meetings, literature, and key stakeholders. Three co-authors developed an outline which was discussed and modified with co-authors, working group members, and additional clinical, policy, and community experts in safer conception, HIV, and fertility. Co-authors and working group members developed and approved the final manuscript. Consensus across themes of demand, safer conception strategies, and implementation were identified. There is demand for safer conception services. Access is limited by stigma towards PLWH having children and limits to provider knowledge. Efficacy, effectiveness, safety, and acceptability data support a range of safer conception strategies including ART, PrEP, limiting condomless sex to peak fertility, home insemination, male circumcision, STI treatment, couples-based HIV testing, semen processing, and fertility care. Lack of guidelines and training limit implementation. Key outstanding questions within each theme are identified. Consumer demand, scientific data, and global goals to reduce HIV incidence support safer conception service implementation. We recommend that providers offer services to HIV-affected men and women, and program administrators integrate safer conception care into HIV and reproductive health programs. Answers to outstanding questions will refine services but should not hinder steps to empower people to adopt safer conception strategies to meet reproductive goals.

Stigma gets in my way: Factors affecting client-provider communication regarding childbearing among people living with HIV in Uganda

INTRODUCTION

Many HIV-affected couples living in sub-Saharan Africa desire to have children, but few quantitative studies have examined support for their childbearing needs. Our study explored client-provider communication about childbearing and safer conception among HIV clients in Uganda.

METHODS

400 Ugandan HIV clients in committed relationships and with intentions to conceive were surveyed. Knowledge, attitudes and practices related to childbearing, and use of safer conception methods were assessed, including communication with providers about childbearing needs, the correlates of which were examined with bivariate statistics and logistic multivariate analysis.

RESULTS

75% of the sample was female; 61% were on antiretroviral therapy; and 61% had HIV-negative or unknown status partners. Nearly all (98%) reported the desire to discuss childbearing intentions with their HIV provider; however, only 44% reported such discussions, the minority (28%) of which was initiated by the provider. Issues discussed with HIV providers included: HIV transmission risk to partner (30%), HIV transmission risk to child (30%), and how to prevent transmission to the child (27%); only 8% discussed safer conception methods. Regression analysis showed that those who had communicated with providers about childbearing were more likely to have been diagnosed with HIV for a longer period [OR (95% CI) = 1.09 (1.03, 1.15)], while greater internalized childbearing stigma was associated with lower odds of this communication [OR (95% CI) = 0.70 (0.49, 0.99)], after controlling for all bivariate correlates and basic demographics.

CONCLUSIONS

Communication between HIV clients and providers about childbearing needs is poor and associated with stigma. Innovations to mitigate stigma among clients as well as training to improve health worker communication and skills related to safer conception counseling is needed.

Achieving pregnancy safely for HIV-serodiscordant couples: a social ecological approach

The recognition and fulfilment of the sexual and reproductive health and rights (SRHR) of all individuals and couples affected by HIV, including HIV-serodiscordant couples, requires intervention strategies aimed at achieving safe and healthy pregnancies and preventing undesired pregnancies. Reducing risk of horizontal and vertical transmission and addressing HIV-related infertility are key components of such interventions. In this commentary, we present challenges and opportunities for achieving safe pregnancies for serodiscordant couples through a social ecological lens. At the individual level, knowledge (e.g. of HIV status, assisted reproductive technologies) and skills (e.g. adhering to antiretroviral therapy or pre-exposure prophylaxis) are important. At the couple level, communication between partners around HIV status disclosure, fertility desires and safer pregnancy is required. Within the structural domain, social norms, stigma and discrimination from families, community and social networks influence individual and couple experiences. The availability and quality of safer conception and fertility support services within the healthcare system remains essential, including training for healthcare providers and strengthening integration of SRHR and HIV services. Policies, legislation and funding can improve access to SRHR services. A social ecological framework allows us to examine interactions between levels and how interventions at multiple levels can better support HIV-serodiscordant couples to achieve safe pregnancies. Strategies to achieve safer pregnancies should consider interrelated challenges at different levels of a social ecological framework. Interventions across multiple levels, implemented concurrently, have the potential to maximize impact and ensure the full SRHR of HIV-serodiscordant couples.

Client uptake of safer conception strategies: implementation outcomes from the Sakh'umndeni Safer Conception Clinic in South Africa

Introduction: Implementation of safer conception services for HIV-affected couples within primary healthcare clinics in resource-limited settings remains limited. We review service utilization and safer conception strategy uptake during the first three years of Sakh’umndeni, which is a safer conception clinic in South Africa.

Methods:Sakh’umndeni is located at Witkoppen Health and Welfare Centre, a high-volume primary healthcare clinic in northern Johannesburg. Men and women desiring to conceive in less than or equal to six months and in relationships in which one or both partners are living with HIV are eligible for safer conception services. Clients receive a baseline health assessment and counselling around periconception HIV risk reduction strategies and choose which strategies they plan to use. Clients are followed-up monthly. We describe client service utilization and uptake and continuation of safer conception methods. Factors associated with male partner attendance are assessed using robust Poisson regression.

Results: Overall 440 individuals utilized the service including 157 couples in which both partners attended (55%) and 126 unaccompanied female partners. Over half of the couples (55%) represented were in serodiscordant/unknown status relationships. Higher economic status and HIV-negative status of the women increased male partner involvement, while HIV-negative status of the men decreased male involvement. Regarding safer conception strategies, uptake of antiretroviral therapy initiation (90%), vaginal self-insemination among partnerships with HIV-negative men (75%) and timed condomless intercourse strategies (48%) were variable, but generally high. Overall uptake of pre-exposure prophylaxis (PrEP) was 23% and was lower among HIV-negative men than women (7% vs. 44%, p < 0.001). Male medical circumcision (MMC) was used by 28% of HIV-negative men. Over 80% of clients took up at least one recommended safer conception strategy. Continuation of selected strategies over attempted conception attempts was >60%.

Conclusions: Safer conception strategies are generally used by clients per recommendations. High uptake of strategies suggests that the proposed combination prevention methods are acceptable to clients and appropriate for scale-up; however, low uptake of PrEP and MMC among HIV-negative men needs improvement. Targeted community-based efforts to reach men unlinked to safer conception services are needed, alongside streamlined approaches for service scale-up within existing HIV and non-HIV service delivery platforms.

Safer Conception for Couples Affected by HIV: Structural and Cultural Considerations in the Delivery of Safer Conception Care in Uganda

In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges.

Prevalence and Correlates of Use of Safer Conception Methods in a Prospective Cohort of Ugandan HIV-Affected Couples with Fertility Intentions

We examined the prevalence and correlates of safer conception methods (SCM) use in HIV-affected couples with fertility intentions. A prospective cohort of 400 HIV clients in Uganda who had fertility intentions with their partner was surveyed every 6 months for 24 months. Logistic regression analysis was used to determine individual, relationship and provider level predictors of SCM use. Over one-third (35%) reported any use of timed unprotected intercourse (TUI) during the study; use of other SCM was rare. Baseline predictors of any TUI use included lower social support, greater perceived provider stigma of childbearing, greater SCM awareness, greater control over sexual decision making in the relationship, inconsistent condom use, and the belief that a desire for childbearing impedes condom use. These findings highlight the need for policy and provider training regarding integration of safer conception counselling into family planning and reproductive health services for people living with HIV.

A Novel Safer Conception Counseling Toolkit for the Prevention of HIV: A Mixed-Methods Evaluation in Kisumu, Kenya

Safer conception strategies can prevent HIV transmission between HIV-discordant partners while allowing them to conceive. However, HIV care providers in sub-Saharan Africa report they are not trained in safer conception, and patients are not routinely offered safer conception services. This mixed-methods pilot study evaluated the impact, acceptability, and feasibility of a novel Safer Conception Counseling Toolkit among providers and patients in Kenya. We enrolled 20 HIV-positive women, 10 HIV-discordant couples, and 10 providers from HIV care and treatment clinics. Providers completed questionnaires before/after training, and then counseled HIV-affected patients. Change in patient knowledge was assessed before/after counseling. Qualitative interviews were conducted among providers and patients. The Toolkit was associated with large, significant increases in patient knowledge, and provider confidence, knowledge, and favorable attitudes toward safer conception counseling; 20% felt confident before versus 100% after training (p < 0.01).

Low Receipt and Uptake of Safer Conception Messages in Routine HIV Care: Findings From a Prospective Cohort of Women Living With HIV in South Africa

BACKGROUND

Safer conception strategies may be used by people living with HIV to reduce HIV transmission to partners resulting from condomless sex for conception. The extent to which people living with HIV receive safer conception messages and use risk reduction strategies is largely unknown.

METHODS

We use prospective data from a clinic-based cohort study in Johannesburg, South Africa. Women living with HIV (WLWH) aged 18-35 on antiretroviral therapy (n = 831) completed a baseline survey and ≥1 follow-up visits assessing fertility intentions and pregnancy incidence; an endline survey was administered 1 year postenrollment. Multivariate negative binomial regression models examined differences in the number of condomless sex acts by fertility intentions. Chi-squared statistics compared receipt of safer conception messages by fertility intentions and indicators of safer conception method use by partner HIV status.

RESULTS

The median baseline age of participants was 30.4 years and 25.3% were in serodiscordant partnerships. WLWH trying to conceive were over 3 times more likely to have condomless sex compared with those not trying to conceive (adjusted incidence rate ratio: 3.17, 95% confidence interval: 1.95 to 5.16). Receipt of specific safer conception messages was low, although women with positive fertility intentions were more likely to have received any fertility-related advice compared with those with unplanned pregnancies (76.3% vs. 49.1%, P < 0.001). Among WLWH trying to conceive (n = 111), use of timed unprotected intercourse was infrequent (17.1%) and lower in serodiscordant vs. concordant partnerships (8.5% vs. 26.9%, P = 0.010).

CONCLUSIONS

These findings suggest that clinic and patient-level interventions are needed to ensure that WLWH receive and use safer conception strategies.

Predictors of Infant Age at Enrollment in Early Infant Diagnosis Services in Kenya

Despite the importance of early detection to signal lifesaving treatment initiation for HIV+ infants, early infant diagnosis (EID) services have received considerably less attention than other aspects of prevention of mother to child transmission care. This study draws on baseline data from an on-going cluster randomized study of an intervention to improve EID services at six government hospitals across Kenya. Two logistic regressions examined potential predictors of “on time” (infant ≤6 weeks of age) vs. “late” (≥7 weeks) and “on time” versus “very late” (≥12 weeks) EID engagement among 756 mother-infant pairs. A quarter of the infants failed to get “on time” testing. Predictors of “on time” testing included being informed about EID by providers when pregnant, perceiving less HIV stigma, and mother’s level of education. Predictors of “very late” testing (≥12 weeks of age) included not being informed about EID by providers when pregnant and living farther from services. Findings highlight the importance of ensuring that health care providers actively and repeatedly inform HIV+ mothers of the availability of EID services, reduce stigma by frequently communicating judgment free support, and assisting mothers in early planning for accessing EID services. Extra care should be focused on engaging mothers with less formal education who are at increased risk for seeking “late” EID testing. This study offers clear targets for improving services so that all HIV-exposed infants can be properly engaged in EID services, thus increasing the potential for the best possible outcomes for this vulnerable population.

Safer Conception Methods and Counseling: Psychometric Evaluation of New Measures of Attitudes and Beliefs Among HIV Clients and Providers

With data from 400 HIV clients with fertility intentions and 57 HIV providers in Uganda, we evaluated the psychometrics of new client and provider scales measuring constructs related to safer conception methods (SCM) and safer conception counselling (SCC). Several forms of validity (i.e., content, face, and construct validity) were examined using standard methods including exploratory and confirmatory factor analysis. Internal consistency was established using Cronbach's alpha correlation coefficient. The final scales consisted of measures of attitudes towards use of SCM and delivery of SCC, including measures of self-efficacy and motivation to use SCM, and perceived community stigma towards childbearing. Most client and all provider measures had moderate to high internal consistency (alphas 0.60-0.94), most had convergent validity (associations with other SCM or SCC-related measures), and client measures had divergent validity (poor associations with depression). These findings establish preliminary psychometric properties of these scales and should facilitate future studies of SCM and SCC.

Client and provider knowledge and views on safer conception for people living with HIV (PLHIV)

OBJECTIVE(S)

The childbearing needs of people living with HIV (PLHIV) and the experiences of healthcare providers serving them are explored. We examine provider and client knowledge and views on safer conception methods.

METHODS

The study uses exploratory qualitative research to understand provider and client perspectives on childbearing and safer conception. Interviews were conducted at 3 sites (1 rural, 2 urban) in eThekwini District, KwaZulu-Natal, South Africa between May 2011 and August 2012, including in-depth interviews with 43 PLHIV, 2 focus group discussions and 12 in-depth interviews with providers.

RESULTS

Clients had little knowledge and providers had limited knowledge of safer conception methods. While clients were eager to receive counseling on safer conception, providers had some hesitations but were eager to receive training in delivering safer conception services. Clients and providers noted that biological parentage is a major concern of PLHIV. Clients were willing to use any of the described methods to have biological children but some expressed concerns about potential risks associated with timed unprotected intercourse. Male clients required access to reproductive health information.

CONCLUSIONS

Providers need to routinely initiate discussions with clients about childbearing intentions. Providers need to be enabled with approved guidelines and training to support client access to safer conception methods.

Perspectives of healthcare providers and HIV-affected individuals and couples during the development of a Safer Conception Counseling Toolkit in Kenya: stigma, fears, and recommendations for the delivery of services

Reproduction is important to many HIV-affected individuals and couples and healthcare providers (HCPs) are responsible for providing resources to help them safely conceive while minimizing the risk of sexual and perinatal HIV transmission. In order to fulfill their reproductive goals, HIV-affected individuals and their partners need access to information regarding safer methods of conception. The objective of this qualitative study was to develop a Safer Conception Counseling Toolkit that can be used to train HCPs and counsel HIV-affected individuals and couples in HIV care and treatment clinics in Kenya. We conducted a two-phased qualitative study among HCPs and HIV-affected individuals and couples from eight HIV care and treatment sites in Kisumu, Kenya. We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) to assess the perspectives of HCPs and HIV-affected individuals and couples in order to develop and refine the content of the Toolkit. Subsequently, IDIs were conducted among HCPs who were trained using the Toolkit and FGDs among HIV-affected individuals and couples who were counseled with the Toolkit. HIV-related stigma, fears, and recommendations for delivery of safer conception counseling were assessed during the discussions. One hundred and six individuals participated in FGDs and IDIs; 29 HCPs, 49 HIV-affected women and men, and 14 HIV-serodiscordant couples. Participants indicated that a safer conception counseling and training program for HCPs is needed and that routine provision of safer conception counseling may promote maternal and child health by enhancing reproductive autonomy among HIV-affected couples. They also reported that the Toolkit may help dispel the stigma and fears associated with reproduction in HIV-affected couples, while supporting them in achieving their reproductive goals. Additional research is needed to evaluate the Safer Conception Toolkit in order to support its implementation and use in HIV care and treatment programs in Kenya and other HIV endemic regions of sub-Saharan Africa.

"I Always Worry about What Might Happen Ahead": Implementing Safer Conception Services in the Current Environment of Reproductive Counseling for HIV-Affected Men and Women in Uganda

Background. We explored healthcare provider perspectives and practices regarding safer conception counseling for HIV-affected clients. Methods. We conducted semistructured interviews with 38 providers (medical and clinical officers, nurses, peer counselors, and village health workers) delivering care to HIV-infected clients across 5 healthcare centres in Mbarara District, Uganda. Interview transcripts were analyzed using content analysis. Results. Of 38 providers, 76% were women with median age 34 years (range 24–57). First, we discuss providers' reproductive counseling practices. Emergent themes include that providers (1) assess reproductive goals of HIV-infected female clients frequently, but infrequently for male clients; (2) offer counseling focused on “family planning” and maternal and child health; (3) empathize with the importance of having children for HIV-affected clients; and (4) describe opportunities to counsel HIV-serodiscordant couples. Second, we discuss provider-level challenges that impede safer conception counseling. Emergent themes included the following: (1) providers struggle to translate reproductive rights language into individualized risk reduction given concerns about maternal health and HIV transmission and (2) providers lack safer conception training and support needed to provide counseling. Discussion. Tailored guidelines and training are required for providers to implement safer conception counseling. Such support must respond to provider experiences with adverse HIV-related maternal and child outcomes and a national emphasis on pregnancy prevention.

Multi-level Correlates of Safer Conception Methods Awareness and Attitudes Among Ugandan HIV Clients with Fertility Intentions

Many people living with HIV desire childbearing, but low cost safer conception methods (SCM) such as timed unprotected intercourse (TUI) and manual self-insemination (MSI) are rarely used. We examined awareness and attitudes towards SCM, and the correlates of these constructs among 400 HIV clients with fertility intentions in Uganda. Measures included awareness, self-efficacy, and motivation regarding SCM, as well as demographics, health management, partner and provider characteristics. Just over half knew that MSI (53%) and TUI (51%) reduced transmission risk during conception, and 15% knew of sperm washing and pre-exposure prophylaxis. In separate regression models for SCM awareness, motivation, and self-efficacy, nearly all independent correlates were related to the partner, including perceived willingness to use SCM, knowledge of respondent's HIV status, HIV-seropositivity, marriage and equality in decision making within the relationship. These findings suggest the importance of partners in promoting SCM use and partner inclusion in safer conception counselling.

Attitudes, Knowledge, and Correlates of Self-Efficacy for the Provision of Safer Conception Counseling Among Ugandan HIV Providers

High rates of childbearing desires (59%) and serodiscordant partnerships (50%) among people living with HIV (PHLA) in Uganda highlight the need for safer conception counseling (SCC). Provider attitudes about counseling PLHA on the use of safer conception methods (SCM) have been explored in qualitative studies, but published quantitative investigations are scarce. Data from 57 Ugandan providers were collected to examine providers' attitudes about childbearing among PLHA and engagement in discussions about childbearing, as well as their knowledge, interest, self-efficacy, and intentions to provide SCC. Correlates of self-efficacy for the provision of SCC were explored to inform the development of training programs. Providers reported a general awareness of most SCM, especially timed unprotected intercourse (TUI); but just over half felt they knew enough to counsel clients in the future and all wanted more training. Childbearing was discussed with less than a third of reproductive aged patients and was mostly initiated by patients. Most providers saw value in providing SCC and believed that most aspects of SCM would be acceptable to their clients, but numerous barriers were endorsed. Self-efficacy was greatest among providers who had had more childbearing conversations, greater SCM awareness, perceived fewer barriers and greater intentions to counsel on TUI. Providers evidence fewer stigmatizing attitudes than in the past. However, those who endorsed more stigmatizing attitudes evidenced a trend for reporting lower self-efficacy for providing SCC. Training will need to simultaneously focus on increasing providers' SCC knowledge and skills while instilling a more realistic appraisal of the risks of assisting couples to employ SCM versus doing nothing.

"I don't know if this is right … but this is what I'm offering": healthcare provider knowledge, practice, and attitudes towards safer conception for HIV-affected couples in the context of Southern African guidelines

The 2011 guidelines for safer conception for HIV-affected individuals and couples were adopted by the South African Department of Health in December 2012. We assessed implementation gaps and facilitators and barriers to delivering safer conception services through examining patient and healthcare provider (HCP) experiences. At Witkoppen Health and Welfare Centre, a primary care clinic in Johannesburg, we conducted in-depth interviews (IDIs) with nine HCPs (doctors, nurses, and counselors) and IDIs and focus group discussions with 42 HIV-affected men and women interested in having a child. Data were analyzed using a grounded theory approach. HCPs were supportive of fertility intentions of HIV-affected couples and demonstrated some knowledge of safer conception methods, especially ART initiation to suppress viral load in infected partners. Unfortunately, HCPs did not follow the key recommendation that HCPs initiate conversations on fertility intentions with HIV-affected men and women. Providers and clients reported that conversations about conception only occur when client-initiated, placing the onus on HIV-affected individuals. Important barriers underlying this were the misconception held by some HCPs that uninfected partners in serodiscordant partnerships are "latently" infected and the desire by most HCPs to protect or control knowledge around fertility and safer conception methods out of concern over what clients will do with this knowledge before they are virally suppressed or ready to conceive. Almost all participants who had conceived or attempted conception did so without safer conception methods knowledge. HCP concern over conception readiness, perception of what clients will do with safer conception knowledge, and gaps in safer conception knowledge prevent HCPs from initiating conversations with HIV-affected patients on the issue of childbearing. Examining these findings in the context of existing South African guidelines illuminates areas that need to be addressed to facilitate implementation of the guidelines.

Acceptability and preferences for safer conception HIV prevention strategies: a qualitative study

Safer conception strategies to reduce the HIV transmission risk include antiretroviral therapy for HIV-positive partners, pre-exposure prophylaxis for HIV-negative partners, condomless sex limited to fertile periods, and home-based self-insemination. Resistance to taking treatment or cultural concerns may limit uptake of strategies and intervention success. Understanding the acceptability and preferences between different approaches is important to optimise service delivery. Between February and July 2013, 42 adults (21 HIV-positive and 21 HIV-negative) receiving primary care at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, participated in focus group discussions or in-depth interviews. Themes were analysed using a grounded theory approach. Acceptability of antiretroviral-based strategies varied. Concerns over side effects, antiretroviral treatment duration and beliefs that treatment is only for the sick were common barriers; however, desperation for a child was noted as a facilitator for uptake. HIV-negative men and HIV-positive women had favourable attitudes towards self-insemination, though paternity and safety concerns were raised. Self-insemination was generally preferred over pre-exposure prophylaxis by HIV-negative men, and antiretroviral-based strategies were preferred by couples with HIV-negative female partners, despite concerns raised about condomless sex while virally suppressed. Knowledge about the fertile window was low. A strong counselling component will be required for effective uptake and adherence to safer conception services.

"If I don't use a condom … I would be stressed in my heart that I've done something wrong": Routine Prevention Messages Preclude Safer Conception Counseling for HIV-Infected Men and Women in South Africa

Intended conception likely contributes to a significant proportion of new HIV infections in South Africa. Safer conception strategies require healthcare provider-client communication about fertility intentions, periconception risks, and options to modify those risks. We conducted in-depth interviews with 35 HIV-infected men and women accessing care in South Africa to explore barriers and promoters to patient-provider communication around fertility desires and intentions. Few participants had discussed personal fertility goals with providers. Discussions about pregnancy focused on maternal and child health, not sexual HIV transmission; no participants had received tailored safer conception advice. Although participants welcomed safer conception counseling, barriers to client-initiated discussions included narrowly focused prevention messages and perceptions that periconception transmission risk is not modifiable. Supporting providers to assess clients' fertility intentions and offer appropriate advice, and public health campaigns that address sexual HIV transmission in the context of conception may improve awareness of and access to safer conception strategies.

Application of an ecological framework to examine barriers to the adoption of safer conception strategies by HIV-affected couples

Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient-provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples.

Community perceptions of childbearing and use of safer conception strategies among HIV-discordant couples in Kisumu, Kenya

Introduction

Safer conception strategies (SCS) have the potential to decrease HIV transmission among HIV-discordant couples who desire children. Community perceptions of SCS may influence the scale-up and uptake of these services, but little is known about how communities will react to these strategies. Without community support for SCS, their success as an HIV prevention tool may be limited. The objective of this study is to characterize community perceptions of SCS for HIV-discordant couples in Kisumu, Kenya, to inform ongoing and future safer conception intervention studies in low-resource settings.

Methods

We conducted six focus group discussions and 11 in-depth-interviews in Kisumu, Kenya, among a diverse group (N=59) of community members, including men, women, youth (age 19–25), community health workers and local leaders. An iterative qualitative analysis using a grounded theory approach was employed.

Results and discussion

All participants emphasized the importance of childbearing in their society and the right to have children, regardless of an individual's HIV status. While most participants believed that HIV-discordant couples should be allowed to have children, they discussed several barriers to the uptake of SCS such as HIV-related stigma, fear of HIV transmission to the uninfected partner and child, fear of unfamiliar medical procedures and lack of information among community members and health care providers about HIV prevention interventions that allow safer conception. Access to information, community experiences with successful safer conception interventions, healthcare provider training, male engagement and community mobilization may help overcome these barriers. Though assisted reproduction strategies generated the most negative reactions from participants, our results suggest that with education and explanation of these services, participants express interest in these strategies and want them to be offered in their community.

Conclusions

Many community members noted a need and desire for safer conception education and services in Kisumu. However, community barriers such as fear, stigma and lack of information should be addressed before safer conception interventions can be successfully implemented and delivered. Further research focused on community education, male engagement and healthcare provider training is a crucial next step in delivering safer conception in this region.

Correlates of Use of Timed Unprotected Intercourse to Reduce Horizontal Transmission Among Ugandan HIV Clients with Fertility Intentions

We examined the correlates of use of safer conception methods (SCM) in a sample of 400 Ugandan HIV clients (75 % female; 61 % on antiretroviral therapy; 61 % with HIV-negative or unknown status partners) in heterosexual relationships with fertility intentions. SCM assessed included timed unprotected intercourse, manual self-insemination, sperm washing, and pre-exposure prophylaxis (PrEP). In the 6 months prior to baseline, 47 (12 %) reported using timed unprotected intercourse to reduce risk of HIV infection (or re-infection), none had used manual self-insemination or sperm washing, and two had used PrEP. In multiple regression analysis, correlates of use of timed unprotected intercourse included greater perceptions of partner's willingness to use SCM and providers' stigma of childbearing among people living with HIV, higher SCM knowledge, and desire for a child within the next 6 months. These findings highlight the need for policy and provider training regarding integration of couples' safer conception counselling into HIV care.