"We weren't using condoms because we were trying to conceive": the need for reproductive counseling for HIV-positive women in clinical care

Prevalence and correlates of having sexual and reproductive health priorities met by HIV providers among women living with HIV in a Canadian setting

OBJECTIVE

To: (1) describe the prevalence of key reproductive health outcomes (e.g., pregnancy, unintended pregnancy; abortion); and (2) examine social-structural correlates, including HIV stigma, of having key sexual and reproductive health (SRH) priorities met by participants' primary HIV provider, among women living with HIV.

METHODS

Data were drawn from a longitudinal community-based open cohort (SHAWNA) of women living with HIV. The associations between social-structural factors and two outcomes representing having SRH priorities met by HIV providers ('being comfortable discussing sexual health [SH] and/or getting a Papanicolaou test' and 'being comfortable discussing reproductive health [RH] and/or pregnancy needs') were analyzed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios (AOR) and 95% confidence intervals [95% CIs] are reported.

RESULTS

Of 314 participants, 77.1% reported having SH priorities met while 64.7% reported having RH priorities met by their primary HIV provider at baseline. In multivariable analysis, having SH priorities met was inversely associated with: sexual minority identity (AOR: 0.59, 95% CI: 0.37-0.94), gender minority identity (AOR: 0.52, 95% CI: 0.29-0.95) and recent verbal or physical violence related to HIV status (AOR: 0.55, 95% CI: 0.31-0.97) and positively associated with recently accessing women-centred services (Oak Tree Clinic) (AOR: 4.25, 95% CI: 2.20-8.23). Having RH priorities met was inversely associated with: sexual minority identity (AOR: 0.56, 95% CI: 0.40-0.79), gender minority identity (AOR: 0.45, 95% CI: 0.25-0.81) and being born in Canada (AOR: 0.29, 95% CI: 0.15-0.56) and positively associated with recently accessing women-centred services (AOR: 1.81, 95% CI: 1.29-2.53) and a history of pregnancy (AOR: 2.25, 95% CI: 1.47-3.44).

CONCLUSION

Our findings suggest that there remain unmet priorities for safe SRH care and practice among women living with HIV, and in particular, for women living with HIV with sexual and/or gender minority identity and those who experience enacted HIV stigma. HIV providers should create safe, non-judgmental environments to facilitate discussions on SRH. These environments should be affirming of all sexual orientations and gender identities, culturally safe, culturally humble and use trauma-informed approaches.

Codesigning care improvements for women living with HIV: a patient-oriented deliberative dialogue workshop in Montréal, Quebec

BACKGROUND

Care services have not been sufficiently adapted to meet the comprehensive care needs of women living with HIV. Our study objective was to engage patients and providers in codesigning care recommendations to improve care for this population in the province of Quebec.

METHODS

We conducted a 5-hour deliberative dialogue workshop in April 2019 in Montréal as the final phase of a mixed-methods study investigating comprehensive care for women living with HIV. The study drew on data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Recruitment was guided by a purposive maximum-variation sampling strategy to ensure an appropriate mix of participants and was facilitated by our existing CHIWOS networks. Participants included patients (women living with HIV) and HIV care providers (doctors, nurses, pharmacists). The workshop was facilitated professionally and included a synthesis of the evidence, small- and large-group deliberations, and voting on care improvements.

RESULTS

Eight patients and 8 HIV care providers participated. Drawing on identified care priorities, the participants identified 4 relatively rapid care improvements and 3 longer-term improvements. The rapid care improvements included delegating medical acts to members of multidisciplinary care teams; greater involvement of HIV community members within care settings and health care decision-making; creating a women's health information booklet; and increasing HIV education among all health care providers and raising awareness of women's care needs beyond HIV-specific care among HIV care providers. The longer-term care improvements included advocating for complete financial coverage of antiretroviral therapy within the government-sponsored Medicare program, facilitating access to allied care providers (e.g., physiotherapists and psychologists) and launching a population-wide campaign to increase awareness about the Undetectable = Untransmittable (U=U) initiative and other HIV advances.

INTERPRETATION

The deliberative dialogue workshop yielded evidence-based, stakeholder-driven recommendations to improve the comprehensive care of women living with HIV in Quebec.

Patient-provider communication about pregnancy and HIV among female sex workers living with HIV in Santo Domingo, Dominican Republic

Background

Health providers can play an important role in communication about pregnancy, particularly for women at increased risk for pregnancy complications, including female sex workers (FSWs) living with HIV. This study explored factors related to patient-provider communication about pregnancy among 253 FSWs living with HIV of reproductive age in Santo Domingo, Dominican Republic.

Methods

A cross-sectional design was employed including structured socio-behavioral surveys. Data were analyzed utilizing bivariate and multivariate logistic regression.

Results

Of the 253 FSWs living with HIV in this study, 95.7% had been pregnant at least once (median: 4; IQR: 3,6), 28.0% wanted more children and 36% reported a pregnancy after HIV diagnosis. Over half of participants (58.0%) reported having ever spoken to a health provider about pregnancy while living with HIV. Multivariate logistic regression found significant associations between having spoken to a health provider about HIV in pregnancy and a more positive perception of their provider (AOR: 2.0; 95% CI: 1.0, 2.5) and years since HIV diagnosis (AOR: 1.1; 95% CI: 1.0, 1.1). Participants were less likely to speak with a provider if they had a history of drug use (AOR: 0.4; 95% CI: 0.2, 0.9) or current alcohol use (AOR: 0.5; 95% CI: 0.3, 0.9).

Conclusion

Findings highlight the importance of non-judgmental and tailored provider-initiated conversations surrounding pregnancy. Future research is needed to better understand how and when pregnancy communication is initiated, as well as the content of clinical care conversations, to address the reproductive health of FSWs living with HIV.

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.

Sexuality and childbearing as it is experienced by women living with HIV in Sweden: a lifeworld phenomenological study

The effectiveness of antiretroviral treatment has reduced sexual HIV transmission and mother-to-child-transmission. To optimally support women living with HIV, health care providers need deepened knowledge about HIV, sexuality and childbearing. The aim of this study was to describe the phenomenon sexuality and childbearing as experienced by women living with HIV in Sweden. Data were collected by phenomenon-oriented interviews with 18 HIV-positive women. A reflective lifeworld analysis based on phenomenological philosophy was conducted, describing the meaning structure of the phenomenon. The essence of the phenomenon is that perceptions about HIV and its contagiousness profoundly influence sexual habits and considerations in relation to pregnancy and childbearing. These perceptions are formed in combination with knowledge and interpretations about HIV by the women themselves and by their environments. The essence is further described by its constituents: Risk of transmission imposes demands on responsibility; The contagiousness of HIV limits sexuality and childbearing; Knowledge about HIV transmission provides confident choices and decisions; and To re-create sexuality and childbearing. Although HIV has a low risk of transmission if being well treated, our study shows that HIV-positive women feel more or less contagious, which influences sexuality and decision-making in relation to become pregnant and give birth.

The Intersection Between Women's Reproductive Desires and HIV Care Providers' Reproductive Health Practices: A Mixed Methods Analysis

Background HIV-positive women in the United States can have healthy pregnancies and avoid transmitting HIV to their children. Yet, little is known about the extent to which HIV care providers' reproductive health practices match women's pregnancy desires. Accordingly, we explored young HIV-positive women's pregnancy desires and reproductive health behaviors and examined reproductive health information offered by HIV care clinics. Methods A mixed-method analysis was conducted using data from a 14-site Adolescent Medicine Trials Network (ATN) study. We conducted descriptive statistics on data from 25 HIV-positive women (e.g., demographics, pregnancy desires, and sexual- and health-related behaviors). Qualitative interviews with 58 adolescent and adult clinic providers were analyzed using the constant comparative method. Results About half of the women reported using reproductive health care services (i.e., contraception and pregnancy tests) (n = 12) and wanted a future pregnancy (n = 13). Among women who did not desire a future pregnancy (n = 5), three used dual methods and two used condoms at last sexual encounter. Qualitative themes related to clinics' approaches to reproductive health (e.g., "the emphasis…is to encourage use of contraceptives") and the complexity of merging HIV and reproductive care (e.g., "We [adolescent clinic] transition pregnant moms from our care back and forth to adult care"). Discussion Despite regular HIV-related medical appointments, HIV-positive women may have unaddressed reproductive health needs (e.g., pregnancy desire with providers focused on contraceptive use). Findings from this study suggest that increased support for young HIV-positive women's reproductive health is needed, including supporting pregnancy desires (to choose when, how, and if, to have children).

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.

Health System Features That Enhance Access to Comprehensive Primary Care for Women Living with HIV in High-Income Settings: A Systematic Mixed Studies Review

Women living with HIV in high-income settings continue to experience modifiable barriers to care. We sought to determine the features of care that facilitate access to comprehensive primary care, inclusive of HIV, comorbidity, and sexual and reproductive healthcare. Using a systematic mixed studies review design, we reviewed qualitative, mixed methods, and quantitative studies identified in Ovid MEDLINE, EMBASE, and CINAHL databases (January 2000 to August 2017). Eligibility criteria included women living with HIV; high-income countries; primary care; and healthcare accessibility. We performed a thematic synthesis using NVivo. After screening 3466 records, we retained 44 articles and identified 13 themes. Drawing on a social-ecological framework on engagement in HIV care, we situated the themes across three levels of the healthcare system: care providers, clinical care environments, and social and institutional factors. At the care provider level, features enhancing access to comprehensive primary care included positive patient-provider relationships and availability of peer support, case managers, and/or nurse navigators. Within clinical care environments, facilitators to care were appointment reminder systems, nonidentifying clinic signs, women and family spaces, transportation services, and coordination of care to meet women's HIV, comorbidity, and sexual and reproductive healthcare needs. Finally, social and institutional factors included healthcare insurance, patient and physician education, and dispelling HIV-related stigma. This review highlights several features of care that are particularly relevant to the care-seeking experience of women living with HIV. Improving their health through comprehensive care requires a variety of strategies at the provider, clinic, and greater social and institutional levels.

Reproduction and Fertility Beliefs, Perceptions, and Attitudes in People Living with HIV

People living with HIV (PLWH) have distinct needs when it comes to reproductive health, specifically regarding fertility, family planning, and pregnancy, and these needs are often complicated by HIV status. While there is ample research that focuses on reproductive health in PLWH through a quantitative lens, there is a lack of research using qualitative methods, namely, the narrative interview model. We searched PubMed and relevant abstracts to identify 72 articles published from 1997 to 2016 that described a qualitative framework for exploring the behaviors and perceptions regarding family planning, abortion, pregnancy, parenthood, fertility, and forced sterility in PLWH. The inclusion criteria initially showed 147 articles, which were further screened to exclude those that did not address fertility and family planning specifically. Our final sample of articles included articles related to qualitative research on reproductive attitudes, beliefs, and behaviors of PLWH. Several of these articles were mixed-methods analyses, but our focus was on the qualitative portion only. Further qualitative works in this area will not only contribute to gaps quantitative research in the field cannot capture by design, but also inform clinical practice, policy, and interventions through systematic, in-depth evaluation.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Fertility desires and preferences for safer conception strategies among people receiving care for HIV at a publicly-funded clinic in Seattle, WA

Understanding fertility desires and preferences for HIV prevention among individuals living with HIV, including the potential use of pre-exposure prophylaxis (PrEP) by HIV uninfected partners, can inform the delivery of safer conception counseling to reduce the risk of HIV transmission during pregnancy attempts. Men and women, predominantly heterosexual, engaged in HIV care in Seattle, WA, self-administered a questionnaire and we abstracted antiretroviral therapy (ART) status and HIV viral levels from medical records. We summarized participants' sexual behavior, fertility desires, and preferences for safer conception strategies and used log-binomial regression to identify demographic, sexual, and behavioral factors associated with perceived acceptability of PrEP for HIV uninfected partners during pregnancy attempts. 52% of the 150 participants were female and the mean age was 48 years (range 23-74). 94.7% of participants were using ART and 79.3% had HIV viral load < 40 copies/mL. 22.2% of men and 34.6% of women reported that a healthcare provider had initiated discussion about fertility desires. 28.7% of participants were reproductive-age and desired children. Among sexually active reproductive-age participants with fertility desires, 56.3% reported inconsistent condom use and 62.5% did not report using effective birth control. 74.4% of reproductive age participants with fertility desires perceived that PrEP would be acceptable to an HIV uninfected partner and there were no significant predictors of PrEP acceptability. Nearly one third of reproductive-aged individuals living with HIV expressed fertility desires, highlighting a need for safer conception counseling in this setting. PrEP and ART were favored safer conception strategies.

Reproductive decision-making in women living with human immunodeficiency virus: A systematic review

OBJECTIVES

Analyze and synthesize the research evidence to understand the reproductive decisions made by women living with HIV from the beginning of the epidemic to the present. Evaluate the barriers and the facilitators for reproductive decision-making. Identify areas of strength, improvement, and those requiring further research.

DESIGN AND DATA SOURCES

Systematic review following the PRISMA guideline. PubMed, CINAHL, PsycINFO, Cochrane Library, SocINDEX, Embase, and Scopus databases were searched from 1985 to 2016 using the following Keywords: HIV, AIDS, pregnancy, reproduction, and decision-making.

STUDY SELECTION

A total of 42 research papers were included in this review. Initially, 1563 papers were identified for the review by database (n=1544) and hand (n=19) searches. With three review levels, 1521 papers were excluded (title review, n=1272; abstract review, n=136; and full paper review, n=113). Studies published in English in peer-reviewed journals using both quantitative and qualitative methods and addressing reproductive decisions in women living with HIV were included. Thirdly, inclusion eligibility was assessed by title, abstract, and full text.

REVIEW METHODS

Random allocation conducted by the primary researcher assigned an equal number of papers to each researcher for review, including detailed instructions with an abstraction form. Discrepancies were resolved by two researchers. Research quality was assessed using the NCHBL Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, the Critical Appraisal Skills Programme for the qualitative studies and its version for systematic reviews RESULTS: The review included 42 papers, both quantitative (n=24) and qualitative methods (n=14). Most studies were completed by physicians (n=16) or nurses (n=15). More than two-thirds of the studies were performed in urban settings with predominantly African-American women (n=27). Eight factors were identified as influencing the reproductive decision-making process in women living with HIV: 'Socio-demographic, Health status and Pregnancy', 'Religion and spirituality', 'Beliefs and Attitudes about Antiretroviral Therapy', 'Healthcare providers', 'Significant others', 'Motherhood and fulfillment', 'Fear of perinatal infection and infection of partner(s)', 'Birth control and pregnancy management'.

CONCLUSIONS

Health care providers are not providing patient-centered care by applying scientific evidence to their practice when advising women with HIV in making reproductive decisions. Despite the strong evidence indicating pregnancy for women with HIV results in a safe birthing trajectory, one not likely to jeopardize the health of the either the mother or fetus, providers continue to recommend the women with HIV avoid pregnancy and neglect to invite partners to participate in the discussion.

Envisioning Women-Centered HIV Care: Perspectives from Women Living with HIV in Canada

BACKGROUND

Women comprise nearly one-quarter of people living with human immunodeficiency virus (HIV) in Canada. Compared with men, women living with HIV experience inequities in HIV care and health outcomes, prompting a need for gendered and tailored approaches to HIV care.

METHOD

Peer and academic researchers from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study conducted focus groups to understand women's experience of seeking care, with the purpose of identifying key characteristics that define a women-centered approach to HIV care. Eleven focus groups were conducted with 77 women living with HIV across Quebec, Ontario, and British Columbia, Canada.

RESULTS

Women envisioned three central characteristics of women-centered HIV care, including i) coordinated and integrated services that address both HIV and women's health care priorities, and protect against exclusion from care due to HIV-related stigma, ii) care that recognizes and responds to structural barriers that limit women's access to care, such as violence, poverty, motherhood, HIV-related stigma, and challenges to safe disclosure, and iii) care that fosters peer support and peer leadership in its design and delivery to honor the diversity of women's experiences, overcome women's isolation, and prioritize women's ownership over the decisions that affect their lives.

CONCLUSION

Despite advances in HIV treatment and care, the current care landscape is inadequate to meet women's comprehensive care needs. A women-centered approach to HIV care, as envisioned by women living with HIV, is central to guiding policy and practice to improve care and outcomes for women living with HIV in Canada.

Pregnancy planning preferences among people and couples affected by human immunodeficiency virus: Piloting a discrete choice experiment

Decision-making related to pregnancy planning is complex and human immunodeficiency virus (HIV) may further complicate the process. With increasing rates of pregnancy among individuals affected by HIV, the need to understand decision-making is imperative. The primary objectives of this pilot study were to confirm the feasibility of using discrete choice experimentation (DCE) to elicit an understanding of this process and to determine the acceptability of the choice factors that were included in two novel DCEs, while gathering a preliminary understanding of preference. The choice attributes were risk of vertical HIV transmission, risk of horizontal HIV transmission, cost, probability of conception, method of conception, and travel time. Thirteen respondents completed a DCE for serodiscordant couples in which the female partner was HIV-positive, and 12 respondents completed a DCE for seroconcordant couples. All respondents' utility for an increased chance of a successful pregnancy was positive and statistically significant. In the serodiscordant dyads, the attributes of risk of horizontal transmission, risk of vertical transmission, a 5-h travel time to clinic, and cost were significantly associated with decreased utility. In the seroconcordant dyads, only the attributes of chance of risk of vertical transmission and cost were significantly associated with decreased utility. The serodiscordant dyads preferred home insemination with a syringe and the seroconcordant couples preferred conception methods within fertility clinics, over condomless sex with timed ovulation. On average, participants were willing to pay more for greater chance of conception and less willing to pay for increased risk of transmission. Couples affected by HIV are willing to participate in a DCE and the attributes that were included all seem relevant except risk of vertical transmission. There are various real-life trade-offs that are made during pregnancy planning with HIV and better understanding of these can be useful for clinicians during preconception counseling.

Divergent Preferences for HIV Prevention: A Discrete Choice Experiment for Multipurpose HIV Prevention Products in South Africa

BACKGROUND

The development of antiretroviral (ARV)-based prevention products has the potential to substantially change the HIV prevention landscape; yet, little is known about how appealing these products will be outside of clinical trials, as compared with the existing options.

METHODS

We conducted a discrete choice experiment (DCE) to measure preferences for 5 new products among 4 important populations in the HIV response: adult men and women in the general population (aged 18 to 49 y), adolescent girls (aged 16 to 17 y), and self-identifying female sex workers (aged 18 to 49 y). We interviewed 661 self-reported HIV-negative participants in peri-urban South Africa, who were asked to choose between 3 unique, hypothetical products over 10 choice sets. Data were analyzed using multinomial, latent class and mixed multinomial logit models.

RESULTS

HIV protection was the most important attribute to respondents; however, results indicate significant demand among all groups for multipurpose prevention products that offer protection from HIV infection, other STIs, and unwanted pregnancy. All groups demonstrated a strong preference for long-lasting injectable products. There was substantial heterogeneity in preferences within and across population groups.

LIMITATIONS

Hypothetical DCE data may not mirror real-world choices, and products will have more attributes in reality than represented in choice tasks. Background data on participants, including sensitive areas of HIV status and condom use, was self-reported.

CONCLUSIONS

These results suggest that stimulating demand for new HIV prevention products may require a more a nuanced approach than simply developing highly effective products. No single product is likely to be equally attractive or acceptable across different groups. This study strengthens the call for effective and attractive multipurpose prevention products to be deployed as part of a comprehensive combination prevention strategy.

Exploring the Factors Considered by People Living with HIV and Their Partners during Preconception

Data are lacking on factors that may impact conception-related decision-making among individuals living with HIV. This study's aim was to shed light on these considerations. Participants were invited to complete a survey on preconception considerations. A rank-ordered logit model was fit to estimate the relative importance of listed consideration factors; the interaction of HIV status and the factors was assessed. Fifty-nine participants living with HIV and 18 partners (11 HIV-negative participants and 7 living with HIV) were included. Risk of vertical and horizontal HIV transmission and the effect of antiretroviral therapy on the fetus were the top considerations. However, individuals living with HIV prioritized vertical transmission, whereas HIV-negative participants prioritized horizontal transmission. Other factors of importance were probability of conception, stress of trying to conceive, cost associated with fertility clinics, and stigma associated with certain conception methods. This study builds our understanding of the preconception considerations for people living with HIV.

Couples Living with HIV

BACKGROUND

Desires to have children are not lessened by a woman's HIV status. Couples may lack information to conceive safely, and men may be especially uninformed. This study examined reproductive intentions, practices, and attitudes among men in HIV-infected couples, including attitudes regarding the perceived risk of vertical and horizontal transmission, safer conception, and preconception planning.

METHODS

Men ( n = 12) in HIV-infected couples were interviewed regarding reproductive intentions, attitudes, and knowledge and qualitative assessments were coded for dominant themes.

RESULTS

Themes primarily addressed concerns about the health of the baby, men's involvement in pregnancy, safer conception, concerns about HIV transmission and antiretroviral therapy, and HIV infection. Men lacked information on safer conception and newer HIV prevention strategies, such as pre-exposure prophylaxis (PrEP).

DISCUSSION

Gaps in knowledge regarding preconception practices among men in HIV-infected couples were identified. Results highlight men's desire for involvement in preconception planning, and opportunities for providers to facilitate this practice and to increase patient education and the use of PrEP are discussed.

Pregnancy Desire, Partner Serodiscordance, and Partner HIV Disclosure among Reproductive Age HIV-Infected Women in an Urban Clinic

Women comprise 25% of the US HIV epidemic, with many women of reproductive age. There is a need for providers to address the reproductive needs and desires of women with HIV given that effective antiretroviral therapy has transformed HIV into a chronic disease. This cross-sectional study shows high rates of partner serodiscordance (61%) and moderate HIV disclosure to partners (61%). Patients surveyed reported practitioners discuss condoms (94%) and contraception (71%) more often than pregnancy desire (38%). In our sample, 44% of the surveyed women intended future pregnancy, whereas women who did not intend future pregnancy cited HIV/health and serodiscordance as the most common reasons (56% and 35%, resp.). There was no difference in the knowledge of mother-to-child transmission risk between women who intended or did not intend future pregnancy (p = 0.71). These results underline the need for provider training in reproductive counseling to promote risk reduction and education.

Pre-Exposure Prophylaxis (PrEP) for Safer Conception Among Serodifferent Couples: Findings from Healthcare Providers Serving Patients with HIV in Seven US Cities

Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV transmission among serodifferent couples trying to conceive, yet provider knowledge, attitudes, and experience utilizing PrEP for this purpose are largely unexamined. Trained interviewers conducted phone interviews with healthcare providers treating patients with HIV in seven cities (Atlanta, Baltimore, Houston, Kansas City, Newark, Philadelphia, and San Francisco, N = 85 total). Quantitative and qualitative data were analyzed to describe experience, concerns, and perceived barriers to prescribing PrEP for safer conception. Providers (67.1% female, 43 mean years of age, 70.4% white, 10 mean years treating HIV+ patients, 56% in academic vs. community facilities, 62.2% MD) discussed both benefits and concerns of PrEP for safer conception among serodifferent couples. Only 18.8% of providers reported experience prescribing PrEP, 74.2% were willing to prescribe it under ideal circumstances, and 7.0% were not comfortable prescribing PrEP. Benefits included added protection and a greater sense of control for the HIV-negative partner. Concerns were categorized as clinical, system-level, cost, or behavioral. Significant differences in provider characteristics existed across sites, but experience with PrEP for safer conception did not, p = 0.14. Despite limited experience, most providers were open to recommending PrEP for safer conception as long as patients understood the range of concerns and could make informed decisions. Strategies to identify and link serodifferent couples to PrEP services and clinical guidance specific to PrEP for safer conception are needed.

Sexuality and Reproduction in HIV-Positive Women: A Meta-Synthesis

The increased access to effective antiretroviral treatment (ART) has made HIV comparable to a chronic disease in terms of life expectancy. Needs related to sexuality and reproduction are central to overall health and well-being. An interpretative meta-synthesis was performed to synthesize and assess how HIV-positive women's experiences of sexuality and reproduction have been described in qualitative studies. A total of 18 peer-reviewed qualitative studies were included, which comprised a total of 588 HIV-positive interviewed women. The studies originated from resource-rich countries outside the Asian and African continents. The analysis, resulting in a lines-of-argument synthesis, shows that HIV infection was a burden in relation to sexuality and reproduction. The weight of the burden could be heavier or lighter. Conditions making the HIV burden heavier were: HIV as a barrier, feelings of fear and loss, whereas motherhood, spiritual beliefs, and supportive relationships made the HIV burden lighter. The findings are important in developing optimal health care by addressing conditions making the burden of HIV infection lighter to bear. In future research there is a need to focus not only on examining how HIV-positive women's sexual and relationships manifest themselves, but also on how health care professionals should provide adequate support to the women in relation to sexuality and reproduction.

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.

Perspectives on safer conception practices and preconception counseling among women living with HIV

Pregnancies are frequently unplanned, and higher rates of unplanned pregnancies occur among HIV-infected women. Reviewers examined reproductive decision making, conception practices, and patient-provider communication among women living with HIV. Qualitative interviews were conducted with 19 HIV-infected sexually active women aged 18-45 in southern Florida, USA. Using thematic analysis, we found decisions to conceive were influenced by women and partners; knowledge and use of safer conception practices were low. Discussion and support from partners, family, and providers was limited and diminished by stigma and nondisclosure. Preconception counseling discussions in HIV care should be comprehensive and initiated frequently by all health care providers.

Determinants and Experiences of Repeat Pregnancy among HIV-Positive Kenyan Women--A Mixed-Methods Analysis

OBJECTIVE

To identify factors associated with repeat pregnancy subsequent to an index pregnancy among women living with HIV (WLWH) in western Kenya who were enrolled in a 24-month phase-II clinical trial of triple-ART prophylaxis for prevention of mother-to-child transmission, and to contextualize social and cultural influences on WLWH's reproductive decision making.

METHODS

A mixed-methods approach was used to examine repeat pregnancy within a 24 month period after birth. Counselor-administered questionnaires were collected from 500 WLWH. Forty women (22 with a repeat pregnancy; 18 with no repeat pregnancy) were purposively selected for a qualitative interview (QI). Simple and multiple logistic regression analyses were performed for quantitative data. Thematic coding and saliency analysis were undertaken for qualitative data.

RESULTS

Eighty-eight (17.6%) women had a repeat pregnancy. Median maternal age was 23 years (range 15-43 years) and median gestational age at enrollment was 34 weeks. In multiple logistic regression analyses, living in the same compound with a husband (adjusted odds ratio (AOR): 2.33; 95% confidence interval (CI): 1.14, 4.75) was associated with increased odds of repeat pregnancy (p ≤ 0.05). Being in the 30-43 age group (AOR: 0.25; 95% CI: 0.07, 0.87), having talked to a partner about family planning (FP) use (AOR: 0.53; 95% CI: 0.29, 0.98), and prior usage of FP (AOR: 0.45; 95% CI: 0.25, 0.82) were associated with a decrease in odds of repeat pregnancy. QI findings centered on concerns about modern contraception methods (side effects and views that they 'ruined the womb') and a desire to have the right number of children. Religious leaders, family, and the broader community were viewed as reinforcing cultural expectations for married women to have children. Repeat pregnancy was commonly attributed to contraception failure or to lack of knowledge about post-delivery fertility.

CONCLUSIONS

In addition to cultural context, reproductive health programs for WLWH may need to address issues related to living circumstances and the possibility that reproductive-decision making may extend beyond the woman and her partner.

Perinatal Depression and Anxiety in Women with and without Human Immunodeficiency Virus Infection

BACKGROUND

Untreated depression and anxiety during the perinatal period have significant consequences on maternal and infant health; however, few studies have examined perinatal depression and perinatal anxiety in women with human immunodeficiency virus (HIV) infection. The current study prospectively examined the prevalence of prenatal and postpartum depression and anxiety, and emotional support from family and friends, as well as childhood sexual abuse in women with and without HIV infection.

METHODS

Between July 2009 and January 2013, 258 pregnant women receiving care in a Philadelphia hospital were enrolled, with 162 completing both the prenatal and postpartum portions of the study. The Center for Epidemiological Studies-Depression Scale (CES-D), and the State-Trait Anxiety Inventory for Adults were used to measure depression and anxiety symptoms, respectively. An independent samples t test and multiple linear regressions were used to determine associations among depression, anxiety, and pregnancy-related variables.

RESULTS

Forty-nine participants (30%) were living with HIV; 113 (70%) were HIV negative. CES-D scores did not differ prenatally (p = .131) or postpartum (p = .156) between women with and without HIV. Prenatal state anxiety scores were higher in women with HIV (p = .02) but there were no differences postpartum (p = .432). In a multiple linear regression, trait anxiety predicted postpartum anxiety in the full sample (p < .001) and childhood sexual abuse predicted postpartum depression among women with HIV (p = .021).

CONCLUSIONS

These findings highlight the importance of identifying and treating perinatal depression and anxiety early in the prenatal period. Results also emphasize the need for providers to be aware of childhood sexual abuse as a potential correlate for depression in women with HIV.

Baseline social characteristics and barriers to care from a special projects of national significance women of color with HIV study: a comparison of urban and rural women and barriers to HIV care

We describe the baseline sociodemographic characteristics of the Health Resources and Services Administration's Special Programs of National Significance Women of Color (WOC) Initiative. Between November 2010 and July 2013, 921 WOC were prospectively enrolled in HIV medical care at nine sites, six urban (N = 641) and three rural sites (N = 280) across the US. We describe the study sample, drawing comparisons between urban and rural sites on sociodemographics, barriers to HIV care, HIV care status at study entry, substance use and sexual risk factors, and the relationship among these variables. Urban sites' participants differed from rural sites on all sociodemographic variables except age (median = 42.3). Women at urban sites were more likely to be Hispanic, less educated, single, living alone, unstably housed, unemployed, and to have reported lower income. More urban women were transferring care to HIV care or had been lost to care. Urban women reported more barriers to care, many relating to stigma or fatalism about HIV care. Urban women reported more substance use and sexual risk behaviors. A better understanding of how HIV care is embedded in communities or fragmented across many sites in urban areas may help understand barriers to long-term engagement in HIV care encountered by WOC.

Messages on pregnancy and family planning that providers give women living with HIV in the context of a Positive Health, Dignity, and Prevention intervention in Mozambique

Background

Family planning is an important HIV prevention tool for women living with HIV (WLHIV). In Mozambique, the prevalence of HIV among women of reproductive age is 13.1% and the average fertility rate is high. However, family planning and reproductive health for WLHIV are under-addressed in Mozambique. This study explores provider descriptions of reproductive health messages in order to identify possible barriers and facilitators to successfully addressing family planning and pregnancy concerns of WLHIV.

Methods

In 2006, a Positive Health, Dignity, and Prevention program was introduced in Mozambique focused on training health care providers to work with patients to reduce their transmission risks. Providers received training on multiple components, including family planning and prevention of mother-to-child transmission (PMTCT). In-depth interviews were conducted with 31 providers who participated in the training in five rural clinics in three provinces. Data were analyzed using qualitative content analysis.

Results

Analysis showed that providers’ clinical messages on family planning, pregnancy, and PMTCT for WLHIV could be arranged along a continuum. Provider statements ranged from saying that WLHIV should not become pregnant and condoms are the only valid form of family planning for WLHIV, to suggesting that WLHIV can have safe pregnancies.

Conclusion

These data indicate that many providers continue to believe that WLHIV should not have children and this represents a challenge for integrating family planning into the care of WLHIV. Also, not offering WLHIV a full selection of family planning methods severely limits their ability to protect themselves from unintended pregnancies and to fully exercise their reproductive rights. Responding to the reproductive health needs of WLHIV is a critical component in HIV prevention and could increase the success of PMTCT programs.

Examining the Traits-Desires-Intentions-Behavior (TDIB) model for fertility planning in women living with HIV in Ontario, Canada

The objective of this study was to determine the predictors of fertility behavior (i.e., trying to become pregnant) in a large representative sample of women living with HIV of reproductive age in Ontario, Canada. The Traits-Desires-Intentions-Behavior model was used to examine the key predictors of reproductive decision making and behavior. A total of 320 women living with HIV were included in the current analysis. The women living with HIV were between the ages of 18 and 52 (mean=37.23, SD=7.53), 56.4% had at least one child living in the home, over 40% identified as being of African ethnicity, and the average time since HIV diagnosis was 10.49 years (SD=5.71). In hierarchical multilevel analysis, perceived family support for trying to become pregnant, living in a large metropolitan city (i.e., Toronto), women's fertility desires, and fertility intentions were associated with fertility behavior (χ(2)9=59.97, p<0.001). As only 10.6% of participants reported engaging in fertility-related behavior, while 57.5% intended a pregnancy in the future, identifying barriers to fertility and discrepancies between intentions and behaviors can support policy programs and assist health care providers to better facilitate the fertility goals of women living with HIV.

HIV+ men need reproductive counseling too: Assessing childbearing goals and provider communication among HIV+ male patients in Rio de Janeiro, Brazil

We assessed reported communication with HIV providers about reproductive plans among HIV+ men in Rio de Janeiro, Brazil, and factors associated with having had such communication. A total of N=311 HIV+ men (18-50 years) receiving HIV care at one of six public primary care clinics in Rio de Janeiro between 2008-2009 were surveyed. We used descriptive statistics, and multivariate logistic regression to identify factors associated with communication about childbearing with an HIV provider. HIV+ male patients (mean age=42.7 years, 57% mixed race; 23% bisexual, 51% married/committed partner, 61% with at least one biological child, 77% on ART) reported accepting attitudes of HIV and childbearing (51%), the desire (39%), and/or intention (19%) to have a future child, and reported communication with the HIV provider (14%) or their primary partner (28%) about having children. There were no significant differences between the responses of HIV+ heterosexual and bisexual men on the above outcomes. Men who discussed childbearing with their HIV provider were more likely to have accepting attitudes about HIV and childbearing [AOR 2.8, 95%CI (1.2-6.4), p=0.014], and intend to have a child [AOR 2.6, 95% CI (1.2-5.6), p=0.018], but less likely to have discussed this topic with their partner [AOR 0.32 (0.15-0.68), p=0.003]. Among men reporting communication, 40% (17/42) reported advice against having a child. An unmet need for collaborative, nonjudgmental, and provider-initiated communication about childbearing goals exists for HIV+ men in clinical care.

Pregnancy intentions among women living with HIV in the United States

BACKGROUND

The number of HIV-infected women giving birth in the United States is increasing. Research on pregnancy planning in HIV-infected women is limited.

METHODS

Between January 1 and December 30, 2012, pregnant women with a known HIV diagnosis before conception at 12 US urban medical centers completed a survey including the London Measure of Unplanned Pregnancy (LMUP) scale. We assessed predictors of LMUP category (unplanned/ambivalent versus planned pregnancy) using bivariate and multivariable analyses.

RESULTS

Overall, 172 women met inclusion criteria and completed a survey. Based on self-report using the LMUP scale, 23% women had an unplanned pregnancy, 58% were ambivalent, and 19% reported a planned pregnancy. Women were at lower risk for an unplanned or ambivalent pregnancy if they had previously given birth since their HIV diagnosis [adjusted relative risk (aRR) = 0.67, 95% confidence interval (CI): 0.47 to 0.94, P = 0.02], had seen a medical provider in the year before the index pregnancy (aRR = 0.60, 95% CI: 0.46 to 0.77, P < 0.01), or had a patient-initiated discussion of pregnancy intentions in the year before the index pregnancy (aRR = 0.63, 95% CI: 0.46 to 0.77, P < 0.01). Unplanned or ambivalent pregnancy was not associated with age, race/ethnicity, or educational level.

CONCLUSIONS

In this multisite US cohort, patient-initiated pregnancy counseling and being engaged in medical care before pregnancy were associated with a decreased probability of unplanned or ambivalent pregnancy. Interventions that promote healthcare engagement among HIV-infected women and integrate contraception and preconception counseling into routine HIV care may decrease the risk of unplanned pregnancy among HIV-infected women in the United States.

Unplanned pregnancies among HIV-infected women in care-United States

OBJECTIVE

To examine the prevalence of unplanned pregnancies among HIV-infected women in care in the United States.

METHODS

We used the 2007-2008 cycles of the Medical Monitoring Project, which collected data on HIV-infected adults in care. Women were included if they had an HIV diagnosis before 45 years of age and responded to questions about pregnancies and pregnancy planning after HIV diagnosis. Logistic regression was used to calculate unadjusted and adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for correlates of unplanned pregnancies among women with ≥ 1 pregnancy at or after an HIV diagnosis.

RESULTS

Of 1492 women, 382 (25.6%) reported ≥ 1 pregnancy after HIV diagnosis (median diagnosis age = 25.0 years; interquartile range = 21.0-30.0); 58% were non-Hispanic black, 22% Hispanic, and 15% non-Hispanic white. Of those, 326 (85.3%) reported ≥ 1 unplanned pregnancy; 124 (32.5%) reported recent unprotected vaginal and/or anal sex with a male partner with either negative or unknown HIV status. Unplanned pregnancies were more likely among women who reported nadir CD4 cell counts <200 cells/μL (AOR = 2.3; 95% CI: 1.2 to 4.8) or did not report nadir CD4 cell counts (AOR = 4.3; 95% CI: 1.9 to 10.5) compared with women who reported nadir CD4 cell counts ≥ 200 cells/μL; and who received public assistance in the most recent year before Medical Monitoring Project interview (AOR = 2.1; 95% CI: 1.1 to 3.8) compared with women who did not receive assistance.

CONCLUSIONS

Unplanned pregnancies were prevalent among our sample. To avoid unplanned pregnancies, HIV-infected women need access to effective family planning services and risk reduction discussions during routine care visits.

The reproductive health behaviors of HIV-infected young women in the United States: A literature review

HIV-infected young women in the United States have important reproductive health needs that are made more complex by their HIV status. We searched Pubmed and relevant bibliographies to identify 32 articles published from 2001 to July 2012 that described the prevalence, correlates, and characteristics of the sexual activity, relationships, pregnancy intentions, HIV status disclosure, and contraceptive and condom use among US HIV-infected adolescents and young women. Our synthesis of those articles found that, like youth not infected with HIV, substantial proportions of HIV-infected youth were sexually active, and most sought romantic or sexual relationships, though their serostatus may have affected the pace of physical and emotional intimacy. Disclosure was difficult, and large proportions of HIV-infected youth had not disclosed their serostatus to recent partners. A few studies suggest that most HIV-infected young women hoped to have children in the future, but many wanted to avoid pregnancy until later. Only one study described contraceptive use among this population in detail and found that condoms were a primary method of contraception. The results point to substantial gaps in published research, particularly in the areas of pregnancy intentions and contraceptive use. Much more needs to be done in research and health services to better understand and meet the complex health needs of HIV-infected young women.

Experiences with HIV testing, entry, and engagement in care by HIV-infected women of color, and the need for autonomy, competency, and relatedness

Self-determination theory examines the needs of people adopting new behaviors but has not been applied to the adoption of HIV healthcare behaviors. The current study applied self-determination theory to descriptions of healthcare behaviors adopted by ethnic minority women after an HIV diagnosis. Women of color were asked to describe their experiences with HIV testing, entry, and engagement-in-care in qualitative interviews and focus groups. Participants were mostly African-American (88%), over 40 years old (70%), had been diagnosed for more than 6 years (87%) and had disclosed their HIV infection to more than 3 people (73%). Women described unmet self-determination needs at different time points along the HIV Continuum of Care. Women experienced a significant loss of autonomy at the time of HIV diagnosis. Meeting competency and relatedness needs assisted women in entry and engagement-in-care. However, re-establishing autonomy was a key element for long-term engagement-in-care. Interventions that satisfy these needs at the optimal time point in care could improve diagnosis, entry-to-care, and retention-in-care for women living with HIV.

Engaging HIV care providers in conversations with their reproductive-age patients about fertility desires and intentions: a historical review of the HIV epidemic in the United States

Provider-initiated conversations with people living with HIV about reproductive plans are lacking. Providers must know whether their patients want to bear children to tailor treatment and refer for HIV preconception counseling to help achieve patients' reproductive goals while minimizing transmission to partners and children. The early focus on men who have sex with men largely excluded consideration of the epidemic's impact on reproductive health. We used a historical review of the US epidemic to describe the problem's scope and understand if this legacy underlies the current neglect of reproductive planning. Drawing on peer-reviewed literature, we discuss key themes relevant to assessing and understanding attention to desires for children among HIV-positive people. We conclude with recommendations for addressing persistent stigma and enhancing patient-provider communication about reproductive intentions.