My partner wants a child: a cross-sectional study of the determinants of the desire for children among mutually disclosed sero-discordant couples receiving care in Uganda

Marriage and Fertility Desire and Associated Factors Among Unmarried People Living With HIV in Jinan, China

ABSTRACT

The desires for marriage and fertility among people living with HIV (PLWH) are increasing worldwide because of improved treatment and prognosis; yet they remain understudied in China, which has a family-oriented culture. This study aimed to investigate these desires for marriage and fertility among Chinese PLWH and explore their correlates. A cross-sectional study was conducted among 1,504 Chinese PLWH to assess their desires for marriage, fertility, and other variables through an online questionnaire. Logistic regression models were used to analyze factors associated with desires for marriage and fertility. Among the 1,504 participants, 53.9% aspired to marry at 34.76 ± 5.26 years old, whereas 62.0% desired parenthood at 36.43 ± 5.11 years old. Factors associated with these desires included age, gender, residence, education level, HIV transmission route, CD4 + T-cell count, time since HIV diagnosis, disclosure of HIV status, social support, and mental health indicators.

Perinatal loss in Tanzania: Perspectives of maternal-child healthcare providers

Over 98% of stillbirths and neonatal deaths occur in Low- and Middle-Income Countries, such as Tanzania. Despite the profound burden of perinatal loss in these regions, access to facility or community-based palliative and psychosocial care is poor and understudied. In this study we explore perinatal loss through the lens of front-line healthcare providers, to better understand the knowledge and beliefs that guide their engagement with bereaved families. A Knowledge Attitudes and Practices survey addressing perinatal loss in Tanzania was developed, translated into Swahili, and administered over a 4-month period to healthcare professionals working at the Kilimanjaro Christian Medical Center (KCMC). Results were entered into REDCap and analyzed in R Studio. 74 providers completed the survey. Pediatric providers saw a yearly average of 5 stillbirths and 32.7 neonatal deaths. Obstetric providers saw an average of 11.5 stillbirths and 13.12 neonatal deaths. Most providers would provide resuscitation beginning at 28 weeks gestational age. Respondents estimated that a 50% chance of survival for a newborn occurred at 28 weeks both nationally and at KCMC. Most providers felt that stillbirth and neonatal mortality were not the mother's fault (78.4% and 81.1%). However, nearly half (44.6%) felt that stillbirth reflects negatively on the woman and 62.2% agreed that women are at higher risk of abuse or abandonment after stillbirth. A majority perceived that women wanted hold their child after stillbirth (63.0%) or neonatal death (70.3%). Overall, this study found that providers at KCMC perceived that women are at greater risk of psychosocial or physical harm following perinatal loss. How women can best be supported by both the health system and their community remains unclear. More research on perinatal loss and bereavement in LMICs is needed to inform patient-level and health-systems interventions addressing care gaps unique to resource-limited or non-western settings.

The impacts of family planning and HIV service integration on contraceptive prevalence among HIV positive women in Tanzania: a comparative analysis from the 2016/17 Tanzania HIV impact survey

BACKGROUND

Prevention of unplanned pregnancies through modern contraceptives among HIV-positive women is one of the essential strategies for reducing mother-to-child transmission of HIV. Family planning and HIV services integration is a national strategy designed to scale-up modern contraceptives among HIV-positive women. This study aims to evaluate the success of a service integration strategy by comparing the prevalence of modern contraceptive use among HIV-positive women receiving ART within integrated services and those not on integrated services (HIV-negative women and HIV-positive women unaware of their status).

METHODS

We used data from the Tanzania HIV impact survey (THIS) of 2016/17. THIS provided HIV counselling and testing with a return of results in over 30,000 adults over 15 years of age. Women tested positive self reported their enrollment into ARV with further confirmation through laboratory analysis for any detectible ARV in their blood. All non-pregnant women reported their contraceptive use. Univariate and multivariate logistic regression was used to assess the effect of accessing integrated services controlling for potential confounders.

RESULTS

A total of 14,986 women were included in the analysis; HIV-positive women were 1,066 and HIV-negative women were 13,830. Modern contraceptive use prevalence was 35% among HIV-positive women and 30% among HIV-negative women. Among HIV-positive women, those enrolled in integrated services (ART) had a higher prevalence of modern contraceptive (40%) compared to HIV-positive women unaware of their status (27%, p-value = 0.0014). The most common contraceptive methods in HIV-positive women were injectables (32%) and male condoms (31%), while in HIV-negative women, injectables (39%) and implants (30%, n = 1032) were the most preferred methods. Among HIV-positive women, enrolment into integrated services (currently on ART) demonstrated an increase in the odds of modern contraceptives by 85% (AOD = 1.85, 95%CI: 1.27-2.71).

CONCLUSION

This study found relatively low modern contraceptive use among HIV-positive women in the general population despite the existance of service integration program and guidelines to guide its implementation.Our study therefore calls for the evaluation on the implementation of the integration programme to identify factors that constrain or facilitate programme effectiveness.

Effects of (In)Congruency in Fertility Motivation on Fertility Desire and Intention Among Couples Living with HIV: A Dyadic Approach

Background

Fertility decision-making plays a negligible role in completing fertility goals among couples living with HIV (CLWH). Being commonly matched concerning fertility motivation seems essential for fertility desire/intention. Few studies report on intra-couple congruences or incongruences in fertility motivation on desire/intention. This study aims to assess the effects of (in)congruency in fertility motivation on fertility desire and intention among couples living with HIV.

Methods

This study uses the actor-partner interdependence model (APIM) to assess the independent direct and indirect effect of fertility motivation on intention, and dyadic response surface analysis with congruency/incongruent effect (DRSA) of fertility motivation on intention using fertility desire as mediator variable among CLWH. CLWH were selected from a clinic in Kunming, China, between October and December 2020. Cross-sectional research included 314 CLWH.

Results

APIM revealed that the wife's fertility motivation had an indirect influence on fertility intention of couples mediated by her fertility desire (R2 = 0.42). There was a significant effect on fertility intention by interaction of (in)congruency in fertility motivation among couples. DRSA shows that linear congruency in fertility motivation of both husband and wife increased fertility desire and intention of couples. However, if there was an incongruent in fertility motivation among husband and wife, husband's domination in fertility motivation was common and negatively affect the wife's fertility desire to have a child. Overall, couples who were matched on fertility motivation reported a significant greater relationship with fertility intention than couples who were mismatched.

Conclusion

Counseling could help both the husband and wife achieve a greater positive fertility intention by addressing comparable fertility goals.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Reproductive Desire in Women Living with HIV/AIDS with Serodiscordant Partners

OBJECTIVE

To estimate the prevalence and factors associated with reproductive desire in a sample of women living with HIV/AIDS (WLHA) with serodiscordant partners.

STUDY DESIGN

Between September 2015 and August 2016, a cross-sectional study was conducted among 110 WLHA from HIV/AIDS treatment services and non-governmental organizations. An interview was conducted using a structured questionnaire to collect sociodemographic data, reproductive desire, and potential predictor variables. Poisson regression was used to analyze the factors associated with reproductive desire in the sample.

RESULTS

The prevalence of reproductive desire was 32.7% (95% Confidence Interval: % CI: 24.7-42.0%). In regression analysis, we observed an association between reproductive desire and the following variables: age < 30 years; relationship time < 2 years; reproductive desire for the partner; and absence of children.

CONCLUSIONS

The prevalence of reproductive desire in the investigated sample was relatively high. Young age and reproductive desire for the partner were the main associated factors.

Untapped Potential for Safer Conception Messaging to Transform PrEP Rollout and Promote Service Engagement Among Serodiscordant Couples

Uptake of pre-exposure prophylaxis (PrEP) fell short of targets for Sub-Saharan Africa's initial rollout, revealing the need for more effective promotion strategies. In Uganda, we explored potential benefits and challenges of integrating safer conception messaging to promote PrEP among serodiscordant couples. In-depth interviews were conducted with clients and personnel at three clinics and analyzed thematically. Participants (n = 58) valued PrEP as a safer conception method (SCM) but described lack of integration of safer conception and PrEP services as well as inconsistent practices in prescribing PrEP to couples pursuing conception. Participants reported that the wider population remains largely unaware of PrEP and SCM or harbors misconceptions that PrEP is primarily for highly stigmatized groups like sex workers. Participants further described how heterosexual couples can still be reluctant to test for HIV, unaware of tools like PrEP and SCM that would allow them to continue their relationship and/or pursuit of childbearing. Overall, findings suggest that integrating PrEP and SCM in messaging and services targeting serodiscordant couples holds untapped benefits throughout the HIV prevention cascade.

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

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

Experiences of HIV Positive Serostatus Disclosure to Sexual Partner Among Individuals in Discordant Couples in Mbarara City, Southwestern Uganda

Purpose

Disclosure of HIV status is key in HIV management. Despite many studies on serostatus disclosure, there is a gap in experiences regarding HIV status disclosure among discordant couples. The current study addressed this research gap, and explored the lived experiences of serostatus disclosure among discordant couples in Mbarara City, South Western Uganda.

Participants and Methods

We conducted 12 in-depth interviews with the help of a translated interview guide, and they were audio recorded. Participants were purposively enrolled in the study, which employed a phenomenological qualitative design. The study was conducted at three public health facilities in Mbarara City. The data was analyzed using thematic content analysis. Approval for this research was obtained from the Mbarara University Research Ethics Committee (MUST-REC) and administrative clearance from the city clerk of Mbarara City.

Results

The mean age of the participants was 38 years old, ranging from 20 to 67 years. An equal number of males (six) and females participated in this study. Most of them had at least secondary level education, and only three had primary education. Half of the participants disclosed their serostatus to partners immediately after testing HIV positive. Key emerging themes as experienced benefits of HIV serostatus disclosure included: 1) social support and care; 2) decisions regarding health, fertility, and child bearing; 3) sharing information on HIV prevention and protection measures; 4) positive living; and 5) ease of HIV serostatus disclosure. The challenges associated with serostatus disclosure were summarized as one theme: misunderstandings in the families of the discordant couples.

Conclusion

Socially, psychologically and financially HIV positive individuals have benefited from their negative partners. Healthwise, they have been supported, and cared for after disclosing their positive status, but some have faced challenges, such as family misunderstandings. Couple HIV counseling and testing by a trained health worker is beneficial in HIV care and could mitigate the challenges related HIV serostatus disclosure.

A national recruitment strategy for HIV-serodiscordant partners living in Canada for the Positive Plus One study: a mixed-methods study

Background

With the recent shift in focus to addressing HIV risk within relationships and couple-based interventions to prevent HIV transmission, successful recruitment of individuals involved in HIV-serodiscordant relationships is crucial. This paper evaluates methods used by the Positive Plus One (PP1) study to recruit and collect data on a diverse national sample of dyads and individuals involved in current or past HIV-serodiscordant relationships, discusses the strengths and limitations of the recruitment approach, and makes recommendations to inform the interpretation of study results and the design of future studies.

Methods

PP1 used a multi-pronged approach to recruit adults involved in a current or past HIV-serodiscordant relationship in Canada from 2016 to 2018 to complete a survey and an interview. Upon survey completion, index (first recruited) partners were invited to recruit their primary current HIV-serodiscordant partner. We investigated participant enrollment by recruitment source, participant-, relationship-, and dyad-level sociodemographic characteristics, missing data, and correlates of participation for individuals recruited by their partners.

Results

We recruited 613 participants (355 HIV-positive; 258 HIV-negative) across 10 Canadian provinces, including 153 complete dyads and 307 individuals who participated alone, and representing 460 HIV-serodiscordant relationships. Among those in current relationships, HIV-positive participants were more likely than HIV-negative participants to learn of the study through an ASO staff member (36% v. 20%, p < 0.001), ASO listserv/newsletter (12% v. 5%, p = 0.007), or physician/staff at a clinic (20% v. 11%, p = 0.006). HIV-negative participants involved in current relationships were more likely than HIV-positive participants to learn of the study through their partner (46% v. 8%, p < 0.001). Seventy-eight percent of index participants invited their primary HIV-serodiscordant partner to participate, and 40% were successful. Successful recruitment of primary partners was associated with longer relationship duration, higher relationship satisfaction, and a virally suppressed HIV-positive partner.

Conclusions

Our findings provide important new information on and support the use of a multi-pronged approach to recruit HIV-positive and HIV-negative individuals involved in HIV-serodiscordant relationships in Canada. More creative strategies are needed to help index partners recruit their partner in relationships with lower satisfaction and shorter duration and further minimize the risk of “happy couple” bias.

A qualitative exploration to understand barriers and facilitators to daily oral PrEP uptake and sustained adherence among HIV-negative women planning for or with pregnancy in rural Southwestern Uganda

INTRODUCTION

Antiretroviral pre-exposure prophylaxis (PrEP) may reduce periconception and pregnancy HIV incidence among women in settings, where gender power imbalances limit HIV testing, engagement in care and HIV viral suppression. We conducted qualitative interviews to understand factors influencing periconception and pregnancy PrEP uptake and use in a cohort of women (Trial registration: NCT03832530) offered safer conception counselling in rural Southwestern Uganda, where PrEP uptake was high.

METHODS

Between March 2018 and January 2019, in-depth interviews informed by conceptual frameworks for periconception risk reduction and PrEP adherence were conducted with 37 women including those with ≥80% and <80% adherence to PrEP doses measured by electronic pill cap, those who never initiated PrEP, and seven of their male partners. Content and dyadic analyses were conducted to identify emergent challenges and facilitators of PrEP use within individual and couple narratives.

RESULTS

The median age for women was 33 years (IQR 28, 35), 97% felt likely to acquire HIV and 89% initiated PrEP. Individual-level barriers included unwillingness to take daily pills while healthy, side effects and alcohol use. Women overcame these barriers through personal desires to have control over their HIV serostatus, produce HIV-negative children and prevent HIV transmission within partnerships. Couple-level barriers included nondisclosure, mistrust and gender-based violence; facilitators included shared goals and perceived HIV protection, which improved communication, sexual intimacy and emotional support within partnerships through a self-controlled method. Community-level barriers included multi-level stigma related to HIV, ARVs/PrEP and serodifference; facilitators included active peer, family or healthcare provider support as women aspired to safely meet socio-cultural expectations to conceive and preserve serodifferent relationships. Confidence in PrEP effectiveness was promoted by positive peer experiences with PrEP and ongoing HIV testing.

CONCLUSIONS

Multi-level forms of HIV-, serodifference- and disclosure-related stigma, side effects, pill burden, alcohol use, relationship dynamics, social, professional and partnership support towards adaptation and HIV risk reduction influence PrEP uptake and adherence among HIV-negative women with plans for pregnancy in rural Southwestern Uganda. Confidence in PrEP, individually controlled HIV prevention and improved partnership communication and intimacy promoted PrEP adherence. Supporting individuals to overcome context-specific barriers to PrEP use may be an important approach to improving uptake and prolonged use.

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.

Sexual behavior and contraceptive practices: Study among married heterosexual HIV serodiscordant couples of reproductive age group attending anti-retroviral therapy centre at a Tertiary care hospital in Mumbai, India

Background:

As many as half of people with HIV who are in a long-term sexual relationship have an HIV-negative partner. Data on sexual behavior and contraceptive needs of heterosexual serodiscordant couples are scarce in India. Keeping these facts in mind, it was considered imperative to conduct a study on sexual behavior, contraceptive practices and associated high risk factors among heterosexual serodiscordant couples.

Objectives:

The objective of the study was to assess the sexual behavior, current contraceptive practices and various risk factors of HIV transmission among married heterosexual HIV serodiscordant couples.

Materials and Methods:

Descriptive study conducted at antiretroviral therapy (ART) centre from where 100 discordant couples were included, data were collected related to their sexual practices, knowledge about different contraception methods and high risk factors related to infection transmission were recorded.

Results:

All couples had knowledge of use of condoms (100%) while consistent usage was seen only in 18%. The high risk of HIV transmission was seen among recently married serodiscordant couples. Couples engaged in daily intercourse were more likely to have high risk of transmission (P value < 0.05).

Conclusion:

This study showed various risk factors for infection transmission to the seronegative partner among serodiscordant couples. Henceforth, given conception that prevention of these factors could reduce overall seroconversion rate among such couples.

Experiences With Safer Conception Services for HIV-Serodiscordant Couples at a Referral Hospital in Nairobi, Kenya

Human immunodeficiency virus-serodiscordant couples are an important source of new HIV infections in Africa. When trying to conceive, uninfected partners may be at high risk of infection if the infected partner is not virally suppressed. Multiple strategies targeting safer conception exist, but these services are limited. However, when services are available and used, serodiscordant couples can be protected from HIV transmission, and safe to have children if desired. To successfully introduce, integrate, promote, and optimize the service delivery of safer conception with HIV care, it is crucial to understand how HIV-serodiscordant couples perceive and experience these services. Further, viral load monitoring can be critical to safer conception, but there is limited literature on how it informs the decision of the partners about conception. This qualitative study describes the knowledge, perceptions, and experiences of both safer conception services and viral load monitoring among 26 HIV-serodiscordant couples seeking safer conception care at a referral hospital in Nairobi, Kenya. In-depth interviews of HIV-serodiscordant couples were conducted from April to July 2017, and transcripts were analyzed to identify the themes central to the experience of safer conception services of couples and viral load monitoring. Serodiscordant couples reported success in using some of the safer conception methods and had positive experiences with healthcare providers. However, despite using the services, some were concerned about HIV transmission to the seronegative partner and baby, while others faced challenges when using pre-exposure prophylaxis (PrEP) and vaginal insemination. Overall, their motivation to have children overcame their concern about HIV transmission, and they welcomed discussions on risk reduction. Moreover, supportive clinic staff was identified as key to facilitating trust in safer conception methods. Furthermore, viral load monitoring was identified as integral to safer conception methods, an emerging theme that requires further evaluation, especially where routine viral load monitoring is not performed. In conclusion, healthcare providers offering safer conception services should build trust with couples, and recognize the need for continual couple counseling to encourage the adoption of safer conception services.

Human immunodeficiency virus and infertility treatment: an Ethics Committee opinion

Human Immunodeficiency Virus is a serious but manageable chronic disease that affects persons of reproductive age, many of whom express a desire for biological parenthood. This document is a revision of the original document of the same name, last published in 2015 (Fertil Steril 2015;104:e1-8).

Which factors predict fertility intentions of married men and women? Results from the 2012 Niger Demographic and Health Survey

INTRODUCTION

Niger is the country with the highest total fertility rate in the world. In the present study, we investigated factors associated with the desire for more children among married men and women in Niger.

MATERIALS AND METHODS

We utilised data from the 2012 Niger Demographic and Health Survey. The outcome variable for the study was fertility intentions. The data were analysed with Stata version 14.0. Both descriptive (frequencies and percentages) and inferential (binary logistic regression) analyses were carried out.

RESULTS

Desire for more children was 97.2% and 87.2% among men and women respectively. Women aged 45-49 were less likely to desire more children, compared to those aged 25-39 [aOR = 0.13, CI = 0.11-0.16]. The odds of desire for more children were high in rural areas, compared to urban areas [aOR = 1.61, CI = 1.20-2.17]. Childbearing women with seven or more births were less likely to desire more children, compared to those with 1-3 births [aOR = 0.09, CI = 0.06-0.14]. Men aged 50-59 were less likely to desire more children, compared to those aged 25-39 [aOR = 0.13, CI = 0.05-0.35]. Men with secondary/higher level of education were less likely to desire more children, compared to those with no formal education [aOR = 0.24, CI = 0.11-0.52]. Childbearing men with seven or more births were less likely to desire more children, compared to those with 1-3 births [aOR = 0.06, CI = 0.01-0.30].

CONCLUSION

This study shows high fertility desire among men and women in Niger. However, the prevalence of fertility desire among men is higher than that of women. A number of socio-economic and demographic factors were found to be associated with desire for more children among men and women in Niger. This calls for a collective effort to educate women and men in Niger on the negative consequences of rapid population growth and large family sizes.

"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.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Prevalence and factors associated with fertility desire among people living with HIV: A systematic review and meta-analysis

BACKGROUND

The fertility desire of people living with HIV (PLHIV) has been rising in the past decade. However, there are many studies among which the association remains controversial between the fertility desire of HIV-infected persons and antiretroviral therapy (ART), sex, marital status, and educational level.

METHODS

We performed a literature search of these meta-analyses in PubMed, the Cochrane Library, Web of Science and ScienceDirect in November 2019. We also reviewed references of eligible studies to complement the search. We used pooled odds ratios (ORs) and 95% confidence intervals (CIs) with a random-effects model and a fixed-effects model to estimate the association between fertility desire among PLHIV and ART, sex, age, marital status, educational level, and number of children. Subgroups with I square values (I2) and sensitivity analyses were performed to assess the heterogeneity and the stability of the overall ORs, respectively. We evaluated publication bias using Egger's test and a visual inspection of the symmetry in funnel plots.

RESULTS

In these meta-analyses 50 articles were included with 22,367 subjects. The pooled prevalence of fertility desire among PLHIV was estimated to be 42.04%. The pooled analyses showed that the fertility desire of PLHIV is associated with ART (OR = 1.11, 95% CI:1.00-1.23, P = 0.043), sex (OR = 1.51, 95% CI:1.10-2.09), age (OR = 2.65, 95% CI:2.24-3.14), marital status (OR = 1.34, 95% CI:1.08-1.66), educational level (OR = 0.85, 95% CI:0.73-1.00, P = 0.047) and the number of children (OR = 3.99, 95% CI:3.06-5.20). PLHIV who are on ART, are male, are younger than 30, are married/cohabiting, have received a secondary education or above, and are childless have a higher prevalence of fertility desire. The two factors of age and the number of children, in particular demonstrated a strong significant association with fertility desire. We found moderate heterogeneity in the meta-analyses of age and educational level and high heterogeneity in the meta-analyses of sex, marital status and number of children. Publication bias was detected in the meta-analyses of the association of fertility with sex and educational level.

CONCLUSION

This study demonstrates that the prevalence of fertility desire among HIV-infected people is 42.04%, and the fertility desire among PLHIV is associated with ART experience, sex, age, marital status, the number of children, and educational level. Since a majority of PLHIV are of reproductive age, it is necessary to support PLHIV in terms of their needs regarding reproductive decision-making. Through counseling and reproductive health care, further measures to prevent the horizontal and vertical transmission of HIV should be taken.

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

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

Reproductive intentions and corresponding use of safer conception methods and contraception among Ugandan HIV clients in serodiscordant relationships

Context

Among people living with HIV in Uganda, desires to have a child and unplanned pregnancies are both common, while utilization of safer conception methods (SCM) and modern contraceptives are low.

Methods

Three hundred eighty-nine HIV clients who reported considering childbearing with their uninfected partner enrolled in a safer conception counseling intervention trial in Uganda. Multiple regression analysis and baseline data were used to examine correlates of reproductive intentions and behaviors, including use of safer conception methods and contraception.

Results

Most (n = 313; 80.5%) reported that both they and their partner wanted to have a child now, which was associated with being married, in a longer relationship, not having a child with partner, greater SCM knowledge, lower internalized childbearing stigma, and higher perceived community stigma of childbearing. However, just 117 reported trying to conceive in the prior 6 months, which was associated with being female, not having a child with their partner, less decision-making control within the relationship, and greater perceived cultural acceptability of SCM. Among those who had tried to conceive in the past 6 months, 14 (11.9%) used SCM, which was associated with greater control in decision making. Of the 268 who were not trying to conceive, 69 (25.7%) were using a modern contraceptive, which was associated with being in a shorter relationship, less control over decision-making, more positive attitudes towards contraception and lower depression.

Conclusion

Methods to promote reproductive goals are underused by HIV serodiscordant couples, and relationships characteristics and childbearing-related stigma appear to be most influential and thus targets for intervention.

Trial registration

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

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10163-7.

Societal and individual drivers of fertility desires and intentions among people living with HIV: a cross sectional study of HIV clinic attendees in Soweto, South Africa

Background

High proportion of people living with HIV (PLHIV) who are in the prime of their reproductive years desire to have children. There are limited studies that explore the range of fertility intentions for PLHIV. This study investigated the fertility desires and intentions of PLHIV and the associated factors.

Methods

This was a cross-sectional study of 442 PLHIV receiving antiretroviral treatment (ART) in health facilities in Soweto, an urban township that is situated in the City of Johannesburg in South Africa. STATA version 13 was used to analyze the data.

Results

The participants' mean age was 36.3 years, 70% were females, 79.6% had at least one biological child, and 36% had 3+ children. Almost half (47%) expressed the desire for children, saying that this was because they had no biological children, or their partners wanted children, or they wanted children of a particular sex, or were feeling healthy after taking ART. An increased fertility desire was associated with absence of biological children (AOR = 5.06, 95% CI: 2.11–12.1) and with being married (AOR = 2.63, 95% CI: 1.31–5.27). A decreased fertility desire was associated with being aged 36+ (AOR = 2.63, 95% CI: 1.31–5.27), having primary education (AOR = 0.11, 95% CI: 0.01–1.30) and having ≥4 years of ART duration (AOR = 0.45, 95% CI: 0.24–0.81).

Conclusion

Individual factors played a significant role in shaping the fertility desires of PLHIV in this setting. The high desire for children underscore the need to integrate reproductive health services in HIV and AIDS care and treatment services and develop safer conception programmes to help PLHIV to conceive and have children safely.

"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.

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

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

Dual contraception method utilization and associated factors among sexually active women on antiretroviral therapy in Gondar City, northwest, Ethiopia: a cross sectional study

BACKGROUND

Mother to child transmission is responsible for 90% of child infection with human immune deficiency virus (HIV). Dual contraceptive use is one of the best actions to prevent mother's human immune deficiency virus transmission to her child and partner. This study aimed at assessing the prevalence and factors associated with dual contraceptive use among sexually active women on antiretroviral therapy in Gondar City, northwest, Ethiopia.

METHODS

An institution based cross sectional study was conducted in Gondar City public health facilities from December 1 to 31, 2018. Systematic random sampling technique was utilized to include 563 study participants. Data were collected by interview using a structured questionnaire. Descriptive analysis was made to compute mean, median and proportion. Finally, multivariable logistic regression model was fitted to identify the factors associated with dual contraceptive method utilization. Analysis was performed by using Statistical Package for Social Sciences (SPSS) software version 20.

RESULTS

The overall prevalence of dual contraceptive method utilization among sexually active women on antiretroviral therapy was 28.8% (95% CI: 24.9, 32.7). Women aged 35-49 years (Adjusted odds ratio (AOR): 6.99; 95% CI: 3.11, 15.71)), who lived in urban areas (AOR: 4.81; 95% CI: 2.04, 11.31), attended secondary and above education (AOR: 4.43; 95% CI: 1.92, 10.22), and disclosed HIV status to sexual partners (AOR: 9.84; 95% CI: 3.48, 27.81) were more likely to use dual contraceptive method.

CONCLUSION

In this study, the proportion of women who utilized dual contraceptive method was low. Age, place of residence, educational status and disclosure of HIV status were factors associated with dual contraceptive use. Therefore, providing education about the advantages of disclosing HIV status to sexual partners and strengthening of counseling about the advantages of dual contraceptive use will be helpful in enhancing the use of dual contraceptive method among sexually active women on antiretroviral therapy.

HIV Serodiscordance among Couples in Cameroon: Effects on Sexual and Reproductive Health

BACKGROUND AND OBJECTIVES

One of the main reasons for risky sexual behavior observed in HIV serodiscordant couples despite the knowledge of the partner's status and counselling is childbearing. In Cameroon, there are few reports on HIV serodiscordant couples. This paper describes the influence of HIV on sexual relationships and decision to procreate.

METHODS

This cross-sectional study was conducted in five health centers. Self-administered questionnaire was used to collect social and demographic information, while semi-structured in-depth individual and couple interviews were used to explore sexual relationships and decisions about fatherhood/motherhood. Blood samples were collected from the couples and tested for HIV to confirm serodiscordance. The data were analyzed using the GraphPad Prism Version 6 software.

RESULTS

A total of 53/192 (27.6%) HIV serodiscordant couples participated in the study, and 18/74 (24.32%) HIV positive seroconcordant couples and 32/80 HIV negative seroconcordant couples were used as controls. The majority of HIV-positive partners in serodiscordant couples were women (30/53), of whom 25/30 were on antiretroviral therapy. Nearly half of the respondents (23 /53) reported tensions related to serodiscordance, shown by reduced sex frequency. The use of condoms was not systematically observed among seroconcordant and serodiscordant couples with respective proportions of 55.55% and 20.75% (p = 0.0086). Thirty seven out of 53 HIV serodiscordant couples wanted children, among them, seven couples did not have any and expressed their aspiration for parenthood despite fear of infecting one's partner.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Sexuality of serodiscordant couples as well as of HIV positive seroconcordant couples was affected by the presence of HIV/AIDS. The desire to procreate may lead couples to adopt risky sexual behaviors. It is important to define specific guidelines for serodiscordant couples in order to improve their sexual life and consequently enable them to procreate with minimal risk of infecting their partner and or to transmit the virus to their baby.

Pregnancy Incidence and Fertility Desires Among Couples by HIV Status in Rakai, Uganda

BACKGROUND

The desire for more children and pregnancy rates are influenced by many relationship dynamics and HIV serostatus of couples.

SETTING

Rakai Community Cohort Study in Uganda.

METHODS

Couple data were retrospectively linked from survey rounds between 2007 and 2015 to assess drivers of fertility desire and pregnancy incidence by HIV status (M-F-; M+F+; M-F+; and M+F-). Multivariable modified Poisson regression was used to estimate prevalence ratios of fertility desire, whereas multivariable Poisson regression was used to estimate incidence rate ratios of pregnancy associated with couple characteristics.

RESULTS

Six thousand six hundred forty-seven couples contributed to 7656 person-years. Approximately 40% of couples (where at least 1 HIV+) desired more children. Unmet need for family planning was evident; couples of medium or low Socioeconomic status and with coresident children had lower fertility desires but higher pregnancy rates. Older age, being in a polygamous union, and having a HIV+ spouse in care were associated with lower fertility desire while having an older male partner was associated with higher fertility desire. Pregnancy incidence was lower with older age, among women using hormonal contraception and condoms, HIV+ concordant couples and couples where the HIV+ spouse was in care while pregnancy incidence were higher among women who desired more children, and serodiscordant couples (M-F+).

CONCLUSIONS

There are many drivers of fertility desires and pregnancy rates, and HIV does not diminish the desire for more children. Unmet need for family planning was evident and highlighted the need to understand and meet the contraceptive needs of couples.

High Incidence of Intended Partner Pregnancy Among Men Living With HIV in Rural Uganda: Implications for Safer Conception Services

BACKGROUND

Many men with HIV express fertility intentions and nearly half have HIV-uninfected sexual partners. We measured partner pregnancy among a cohort of men accessing antiretroviral therapy in Uganda.

METHODS

Self-reported partner pregnancy incidence and bloodwork (CD4, HIV-RNA) were collected quarterly. Interviewer-administered questionnaires assessed men's sexual and reproductive health annually and repeated at time of reported pregnancy (2011-2015). We measured partner pregnancy incidence overall, by pregnancy intention and by reported partner HIV serostatus. We assessed viral suppression (≤400 copies/mL) during the periconception period. Cox proportional hazard regression with repeated events identified predictors of partner pregnancy.

RESULTS

Among 189 men, the baseline median age was 39.9 years (interquartile range: 34.7-47.0), years on antiretroviral therapy was 3.9 (interquartile range: 0.0-5.1), and 51% were virally suppressed. Over 530.2 person-years of follow-up, 63 men reported 85 partner pregnancies (incidence = 16.0/100 person-years); 45% with HIV-serodifferent partners. By 3 years of follow-up, 30% of men reported a partner pregnancy, with no difference by partner HIV serostatus (P = 0.75). Sixty-nine percent of pregnancies were intended, 18% wanted but mistimed, and 8% unwanted. Seventy-eight percent of men were virally suppressed before pregnancy report. Men who were younger [adjusted hazard ratio (aHR): 0.94/yr; 95% confidence interval (CI): 0.89 to 0.99], had incomplete primary education (aHR: 2.95; 95% CI: 1.36 to 6.40), and reported fertility desires (aHR: 2.25; 95% CI: 1.04 to 4.85) had higher probability of partner pregnancy.

CONCLUSIONS

A high incidence of intended partner pregnancy highlights the need to address men's reproductive goals within HIV care. Nearly half of pregnancy partners were at-risk for HIV, and one-quarter of men were not virally suppressed during periconception. Safer conception care provides opportunity to support men's health and reproductive goals, while preventing HIV transmission to women and infants.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS AND DISCUSSION

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

CONCLUSIONS

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

Fertility desire and associated factors among women on the reproductive age group of Antiretroviral treatment users in Jimma Town, South West Ethiopia

OBJECTIVES

HIV remained the major cause of death in women of reproductive age worldwide. There is limited evidence regarding the fertility desire of HIV positive women receiving HIV care in the study area. Therefore, facility based cross-sectional study was conducted from March to April 2017 to assess fertility desire of HIV positive women and associated factors among mothers in receiving HIV care Jimma town, Southwest Ethiopia. Simple random sampling technique was taken to draw the sample after stratification. Data were analyzed using SPSS version 21 and statistical significance was declared at P value less than 0.05.

RESULTS

This finding showed that, 175 (46.8%) of the Antiretroviral therapy users had fertility desire with those significantly associated factors; women in the age 18-29 years [AOR = 4.05, 95% CI 1.24-13.33], being married [AOR = 0.32, 95% CI (0.13-0.78)], having diploma educational level [AOR = 5.34, 95% CI 1.10, 15.60], having only boys or girls children [AOR = 2.79, 95% CI (1.24-6.25)], having 18-36$ monthly income [AOR = 1.27, 95% CI (1.56-10.67)], Partner's HIV status [AOR = 3.56, 95% CI (3.02-9.33)] and non use of contraceptives [AOR = 2.57, 95% CI (1.08-6.13)]. Fertility desire in the study area was high. Strengthening PMTCT service should consider fertility desire of mothers living with HIV.

Men's and women's roles in decision making about abortion in the context of HIV

OBJECTIVE

Mother-to-child transmission of HIV is a matter of global concern but is particularly serious in Zimbabwe. A number of strategies have been identified to limit the risk of mother-to-child transmission, including abortion. The aim of the current study was to assess men's and women's roles in decision making about abortion in a setting with a high prevalence of HIV.

METHODS

Qualitative research based on eight focus group discussions was conducted among adult men and women in Gokwe North District, Zimbabwe.

RESULTS

Both men and women expressed strong, negative attitudes towards abortion. Often, HIV-infected women considered carrying their pregnancy to term so as to fulfil societal and cultural expectations of childbirth after marriage. Termination of pregnancy by HIV-infected women was discouraged due to the availability of highly active antiretroviral drugs. Fear of giving birth to a sick and HIV-infected child, however, remained high. Also, the restricted legal environment appeared to complicate HIV-positive women's decisions to abort. Male involvement in decision making about abortion was relatively limited; if women opted for termination of pregnancy they were likely to do so secretly without obtaining their partner's consent.

CONCLUSIONS

In the context of HIV, it is important for prevention programmes to target both men and women in order to reduce the risk of mother-to-child transmission.

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.

Factors associated with desired fertility among HIV-positive women and men attending two urban clinics in Lilongwe, Malawi

As access to antiretroviral therapy increases, more HIV-infected patients in sub-Saharan Africa may desire fertility. We conducted a cross-sectional study of reproductive health knowledge, attitudes and practices to identify factors associated with desired fertility among women and men receiving care at two large public HIV clinics in Lilongwe, Malawi. Research assistants administered questionnaires to participants. We performed descriptive, bivariable and multivariable analysis of factors related to desired fertility and of factors related to contraceptive non-use among participants who did not desire fertility. One-third of participants desired future children. Having a partner who desired fertility and having lower parity were associated with desiring children among both genders. For women, believing that pregnancy was unhealthy was associated with decreased fertility desire. Fifty-five percent of women and 69% of men who did not want children in the future reported using contraception at last intercourse. Increasing age, lower parity, and making the decision to use contraception herself were associated with contraceptive non-use among women who did not desire fertility. Having discussed family planning with his partner was associated with contraceptive use among men who did not desire fertility. Knowledge of these factors can guide reproductive health counseling and service provision.

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.

Cross-sectional study on the prevalence and predictors of pregnancy among women living in HIV discordant relationships in a rural Rakai cohort, Uganda

OBJECTIVES

This study examines the prevalence of pregnancy in serodiscordant couples and identifies predictors associated with pregnancy in rural Rakai, Uganda.

STUDY DESIGN

A population-based cross-sectional study that used data from the Rakai Community Cohort Study (RCCS).

SETTING AND PARTICIPANTS

We used data from the RCCS survey round 17 (2015-2016), which included 488 women in serodiscordant relationships. This study was conducted in Rakai district, located in south-western Uganda.

PRIMARY OUTCOMES

Pregnancy status.

STATISTICAL ANALYSIS

Multivariable modified Poisson regression using stepwise selection was used to determine characteristics and behaviours associated with pregnancy status.

RESULTS

The prevalence of pregnancy was 12% in women among serodiscordant couples. HIV-negative women in serodiscordant couples had a slightly higher pregnancy prevalence rate (13.6%) compared with HIV-positive women in serodiscordant couples (11%). Factors significantly associated with higher prevalence of pregnancy were; younger age 15-24 years (prevalence risk ratio (PRR)=4.04; 95% CI 1.72 to 9.50), middle age 25-34 years (PRR=2.49; 95% CI 1.05 to 5.89), Christian religion (PRR=2.26; 95% CI 1.41 to 3.63) and inconsistent condom use in the last 12 months (PRR=4.38, 95% CI 1.09 to 17.53). Neither HIV status nor HIV status disclosure was significantly associated with risk of getting pregnant.

CONCLUSION

Nearly 12% of women in serodiscordant relationships were pregnant, highlighting the need for integrated services to prevent unintended pregnancies and reduce conceptional related risks for those choosing to conceive. Association with younger age and inconsistent condom use suggests a role for early and continued couple-based conception counselling.

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.

Modern contraceptive use among women living with HIV/AIDS at the Korle Bu Teaching Hospital in Ghana

OBJECTIVE

To examine factors influencing contraceptive use among women living with HIV/AIDS.

METHODS

The present cross-sectional study included a randomly selected sample of sexually active females aged 15-60 years who were living with HIV/AIDS and receiving care at the HIV Clinic, Korle Bu Teaching Hospital, Accra, Ghana, between September 1 and November 31, 2016. Data were collected via a structured interviewer-administered questionnaire.

RESULTS

Among 202 women who completed the survey, 50 (24.7%) were using contraceptives. Of the women using contraception, 39 (78%) were married and 6 (12%) were cohabiting. Twenty-eight (56%) reported that their primary sexual partners were HIV-positive, 14 (28%) had HIV-negative partners, and 8 (16%) did not know their partner's HIV status. Condoms were used by 42 (84%) women and the majority (41 [82%]) wanted to have more children; almost all (47 [94%]) had received counseling on contraceptive use. Overall, 133 (65.8%) and 45 (22.3%) women reported that they would prefer to share their family planning concerns with a doctor and nurse, respectively, at the HIV clinic.

CONCLUSION

Women living with HIV/AIDS desired more children but preferred to share their family planning concerns with their clinician at the HIV clinic. Integrating HIV care and reproductive health services could help these women achieve childbearing goals safely.

Difficult decisions: Evaluating individual and couple-level fertility intentions and HIV acquisition among HIV serodiscordant couples in Zambia

Introduction

Attempts to conceive and pregnancy may increase HIV transmission to sex partners and infants. Our study evaluated the association between fertility intentions and HIV acquisition among Zambian HIV-serodiscordant couples.

Methods

We collected demographic, behavioral, clinical exposures, and data on fertility intentions in a cohort of HIV-serodiscordant couples in Lusaka, Zambia from 2005 to 2012. We evaluated factors associated with fertility intentions stratified by gender using multivariable logistic regression. Multivariable Cox proportional hazard models were used to evaluate the associations between fertility intentions and HIV acquisition controlling for a priori confounders and covariates that substantially (>10%) changed the effect estimates in univariate analyses.

Results

Among 1,029 serodiscordant couples, 311 agreed that they wanted children in the future (30%), 368 agreed they did not want children (36%), and 344 couples disagreed about having children (34%), with men more likely than women to want children. Women wanting child(ren) was associated with increased odds of baseline pregnancy (adjusted odds ratio [aOR] = 4.80 (95% confidence interval [CI] = 2.93, 7.85)), fewer previous pregnancies (aOR = 0.85 per additional pregnancy (95% CI = 0.78, 0.93)), and partner fertility intention (aOR = 2.89 (95% CI = 2.14, 3.91)) adjusting for woman’s age, literacy, years cohabiting and HIV status. Men wanting child(ren) was associated with younger age (aOR = 0.96 per year (95% CI = 0.93, 0.99)), fewer years cohabiting (aOR = 0.95 (95% CI = 0.92, 0.98)), number of previous partners’ pregnancies (aOR = 0.90 (95% CI = 0.82, 0.98)), and partner fertility intention (aOR = 3.00 (95% CI = 2.21, 4.07)) adjusting for partner’s age, literacy, HIV status and partner’s baseline pregnancy. In adjusted survival analyses, HIV-negative women were more likely to seroconvert if they themselves wanted children (aHR = 2.36 (95% CI = 1.41, 3.96)) vs. did not want children, or if their partner wanted children (aHR = 2.34 (95% CI = 1.33, 4.11)) vs. did not want children, or if the couple agreed that they wanted children (aHR = 2.08 (95% CI = 1.01, 4.30)), adjusting for women’s age, women’s literacy, previous pregnancies and time in study. HIV-negative men were more likely to seroconvert if their female partner wanted a child in the next 12-months (aHR = 1.94 (95% CI = 1.02, 3.68)) vs. did not want children, and when both partners wanted children (aHR = 2.02 (CI = 1.09, 3.73)) vs. they did not want children, adjusting for men’s age and literacy, couple income, number of live children, male circumcision status and time in study.

Conclusion

Women had increased risk of HIV acquisition if they and/or their partner wanted a child, while men had increased risk of HIV acquisition when their partner or if both partners agreed that they wanted children. Safer-conception interventions are needed to protect HIV uninfected women and men from HIV acquisition in HIV-serodiscordant couples who want children.

Supporting HIV prevention and reproductive goals in an HIV-endemic setting: taking safer conception services from policy to practice in South Africa

Introduction: Safer conception care encompasses HIV care, treatment and prevention for persons living with HIV and their partners who desire children. In 2012, South Africa endorsed a progressive safer conception policy supporting HIV-affected persons to safely meet reproductive goals. However, aside from select research-supported clinics, widespread implementation has not occurred. Using South Africa as a case study, we identify key obstacles to policy implementation and offer recommendations to catalyse expansion of these services throughout South Africa and further afield.

Discussion: Four key implementation barriers were identified by combining authors’ safer conception service delivery experiences with available literature. First, strategic implementation frameworks stipulating where, and by whom, safer conception services should be provided are needed. Integrating safer conception services into universal test-and-treat (UTT) and elimination-of-mother-to-child-transmission (eMTCT) priority programmes would support HIV testing, ART initiation and management, viral suppression and early antenatal/eMTCT care engagement goals, reducing horizontal and vertical transmissions. Embedding measurable safer conception targets into these priority programmes would ensure accountability for implementation progress. Second, facing an organizational clinic culture that often undermines clients’ reproductive rights, healthcare providers’ (HCP) positive experiences with eMTCT and enthusiasm for UTT provide opportunities to shift facility-level and individual attitudes in favour of safer conception provision. Third, safer conception guidelines have not been incorporated into HCP training. Combining safer conception with “test-and-treat” training would efficiently ensure that providers are better equipped to discuss clients’ reproductive goals and support safer conception practices. Lastly, HIV-affected couples remain largely unaware of safer conception strategies. HIV-affected populations need to be mobilized to engage with safer conception options alongside other HIV-related healthcare services.

Conclusion: Key barriers to widespread safer conception service provision in South Africa include poor translation of policy into practical and measurable implementation plans, inadequate training and limited community engagement. South Africa should leverage the momentum and accountability associated with high priority UTT and eMTCT programmes to reinvigorate implementation efforts by incorporating safer conception into implementation and monitoring frameworks and associated HCP training and community engagement activities. South Africa’s experiences should be used to inform policy development and implementation processes in other HIV high-burden countries.

Beyond HIV-serodiscordance: Partnership communication dynamics that affect engagement in safer conception care

INTRODUCTION

We explored acceptability and feasibility of safer conception methods among HIV-affected couples in Uganda.

METHODS

We recruited HIV-positive men and women on antiretroviral therapy (ART) ('index') from the Uganda Antiretroviral Rural Treatment Outcomes cohort who reported an HIV-negative or unknown-serostatus partner ('partner'), HIV-serostatus disclosure to partner, and personal or partner desire for a child within two years. We conducted in-depth interviews with 40 individuals from 20 couples, using a narrative approach with tailored images to assess acceptability of five safer conception strategies: ART for the infected partner, pre-exposure prophylaxis (PrEP) for the uninfected partner, condomless sex timed to peak fertility, manual insemination, and male circumcision. Translated and transcribed data were analyzed using thematic analysis.

RESULTS

11/20 index participants were women, median age of 32.5 years, median of 2 living children, and 80% had HIV-RNA <400 copies/mL. Awareness of HIV prevention strategies beyond condoms and abstinence was limited and precluded opportunity to explore or validly assess acceptability or feasibility of safer conception methods. Four key partnership communication challenges emerged as primary barriers to engagement in safer conception care, including: (1) HIV-serostatus disclosure: Although disclosure was an inclusion criterion, partners commonly reported not knowing the index partner's HIV status. Similarly, the partner's HIV-serostatus, as reported by the index, was frequently inaccurate. (2) Childbearing intention: Many couples had divergent childbearing intentions and made incorrect assumptions about their partner's desires. (3) HIV risk perception: Participants had disparate understandings of HIV transmission and disagreed on the acceptable level of HIV risk to meet reproductive goals. (4) Partnership commitment: Participants revealed significant discord in perceptions of partnership commitment. All four types of partnership miscommunication introduced constraints to autonomous reproductive decision-making, particularly for women. Such miscommunication was common, as only 2 of 20 partnerships in our sample were mutually-disclosed with agreement across all four communication themes.

CONCLUSIONS

Enthusiasm for safer conception programming is growing. Our findings highlight the importance of addressing gendered partnership communication regarding HIV disclosure, reproductive goals, acceptable HIV risk, and commitment, alongside technical safer conception advice. Failing to consider partnership dynamics across these domains risks limiting reach, uptake, adherence to, and retention in safer conception programming.

Prevalence of fertility desire and its associated factors among 15- to 49-year-old people living with HIV/AIDS in Addis Ababa, Ethiopia: a cross-sectional study design

Background

The magnitude of unprotected sex to satisfy the desire for fertility among people living with HIV/AIDS (PLHIV) may rise more due to the availability of antiretroviral therapy (ART) in most HIV-affected countries. This could, however, have the risk of passing on HIV to sexual partners and children. The aim of this study, therefore, was to determine the magnitude and factors associated with the fertility desire of reproductive-age PLHIV in Addis Ababa, Ethiopia, for research-based and timely actions.

Methods

A cross-sectional study was carried out from April to June 2016 among 442 randomly selected, reproductive-age PLHIV who had been attending ART clinics in Addis Ababa. Twelve experienced and trained nurses collected the data. The questionnaire was pretested and interviewer-administered, and the interview was executed after obtaining voluntary consent from each study subject. The data were then cleaned and analyzed by using Epi Info version 3.5.4 and SPSS version 20.0, respectively. Binary logistic regression was done in order to describe the association of fertility desire with some sociodemographic and sexual behavior-related factors.

Results

Among the total 441 respondents, 54.6% reported the desire for fertility, 87% disclosed their HIV status, 24.3% had two or more sexual partners in the earlier year, and only 55.6% used a condom during their last sexual intercourse. In addition, current health status (AOR=2.03; 95% CI: 1.01–4.07) and partner being tested for HIV (AOR=6.31; 95% CI: 1.35–29.64) showed statistically significant associations with fertility desire during multivariate logistic regression analysis.

Conclusion

A considerable number of PLHIV in the study area reported a desire for having children. Current health status and partner being tested for HIV were found to be factors associated with the fertility desire among PLHIV. Thus, more efforts to effectively address the health concerns related to fertility desire and risky sexual behavior among HIV-infected people of reproductive age could play a significant role in prevention and control measures against HIV/AIDS epidemic.

Significant rates of risky sexual behaviours among HIV-infected patients failing first-line ART: A sub-study of the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial

There are limited data on the prevalence of risky sexual behaviours in individuals failing first-line antiretroviral therapy (ART) and changes in sexual behaviour after switch to second-line ART. We undertook a sexual behaviour sub-study of Ugandan adults enrolled in the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial. A standardized questionnaire was used to collect sexual behaviour data and, in particular, risky sexual behaviours (defined as additional sexual partners to main sexual partner, inconsistent use of condoms, non-disclosure to sexual partners, and exchange of money for sex). Of the 79 participants enrolled in the sub-study, 62% were female, median age (IQR) was 37 (32-42) years, median CD4 cell count (IQR) was 79 (50-153) cells/µl, and median HIV viral load log was 4.9 copies/ml (IQR: 4.5-5.3) at enrolment. The majority were in long-term stable relationships; 69.6% had a main sexual partner and 87.3% of these had been sexually active in the preceding six months. At enrolment, around 20% reported other sexual partners, but this was higher among men than women (36% versus 6.7 %, p < 0.001). In 50% there was inconsistent condom use with their main sexual partner and a similar proportion with other sexual partners, both at baseline and follow-up. Forty-three per cent of participants had not disclosed their HIV status to their main sexual partner (73% with other sexual partners) at enrolment, which was similar in men and women. Overall, there was no significant change in these sexual behaviours over the 96 weeks following switch to second-line ART, but rate of non-disclosure of HIV status declined significantly (43.6% versus 19.6%, p <0.05). Among persons failing first-line ART, risky sexual behaviours were prevalent, which has implications for potential onward transmission of drug-resistant virus. There is need to intensify sexual risk reduction counselling and promotion of partner testing and disclosure, especially at diagnosis of treatment failure and following switch to second- or third-line ART.

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.

Optimizing Prevention of HIV and Unplanned Pregnancy in Discordant African Couples

BACKGROUND

Dual method use, which combines condoms with a more effective modern contraceptive to optimize prevention of HIV and unplanned pregnancy, is underutilized in high-risk heterosexual couples.

MATERIALS AND METHODS

Heterosexual HIV-discordant Zambian couples were enrolled from couples' voluntary HIV counseling and testing services into an open cohort with 3-monthly follow-up (1994-2012). Relative to dual method use, defined as consistent condom use plus modern contraception, we examine predictors of (1) condom-only use (suboptimal pregnancy prevention) or (2) modern contraceptive use with inconsistent condom use (effective pregnancy prevention and suboptimal HIV prevention).

RESULTS

Among 3,049 couples, dual method use occurred in 28% of intervals in M+F- and 23% in M-F+, p < 0.01; condom-only use in 56% in M+F- and 61% in M-F+, p < 0.01; and modern contraceptive use with inconsistent condom use in 16% regardless of serostatus. Predictors (p < 0.05) of condom-only use included the man being HIV+ (adjusted hazard ratio, aHR = 1.15); baseline oral contraceptive pill (aHR = 0.76), injectable (aHR = 0.48), or implant (aHR = 0.60) use; woman's age (aHR = 1.04 per 5 years) and lifetime number of sex partners (aHR = 1.01); postpartum periods (aHR = 1.25); and HIV stage of the index partner III/IV versus I (aHR = 1.10). Predictors (p < 0.05) of modern contraceptive use with inconsistent condom use included woman's age (aHR = 0.94 per 5 years) and HIV+ male circumcision (aHR = 1.51), while time-varying implant use was associated with more consistent condom use (aHR = 0.80).

CONCLUSIONS

Three-quarters of follow-up intervals did not include dual method use. This highlights the need for counseling to reduce unintended pregnancy and HIV transmission and enable safer conception.

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.

Factors influencing reproductive choices of HIV positive individuals attending primary health care facilities in a South African health district

BACKGROUND

There is global recognition of the reproductive health rights of people living with HIV (PLHIV). The aim of this research study was to explore the reproductive choices, and the factors influencing these choices, of HIV positive patients attending primary health care (PHC) facilities in the Ekurhuleni health district of the Gauteng Province of South Africa.

METHODS

During 2013, a cross-sectional survey was conducted in the Ekurhuleni health district. At each of three randomly selected community health centres, a random sample of HIV positive patients was selected. After informed consent was obtained, trained fieldworkers administered a structured questionnaire that elicited information on socio-demographics, reproductive choices and knowledge of reproductive options. Survey data were analysed using STATA® 13.

RESULTS

The majority of survey participants (n = 430) were female (70%) and unemployed (57%). The mean age of participants was 36.4 years (SD 8.6): 40.8 years (SD 8.7) for men and 34.5 years (SD7.8) for women. Among survey participants, 46% expressed a desire for children (95% CI: 41.4-50.9). In the multiple logistic regression analysis, predictors of desire for children were age less than 49 years, marriage or living together, and no biological children. The odds of wanting children was 16.48 [95% CI: 5.94-45.74] times higher for PLHIV without children, compared with those with two or more children, while for those less than 25 years, the odds of wanting children was 0.78 [95% CI: 0.23-2.59] compared with those older than 50 years. The PLHIV knowledge on the available reproductive options was limited, with the majority relying on the guidance of the health workers.

CONCLUSION

Health care providers at PHC level should be educated to address the reproductive health needs of PLHIV. These aspects should be reflected in provincial and national health policies.

"I Do Not Take My Medicine while Hiding" - A Longitudinal Qualitative Assessment of HIV Discordant Couples' Beliefs in Discordance and ART as Prevention in Uganda

BACKGROUND

HIV negative members of serostatus discordant couples are at high risk for HIV acquisition, but few interventions are in place to target them in sub-Saharan Africa.

METHODS

In this study, we interviewed 28 couples, 3 times over a period of one year to understand their perceptions and attitudes around discordance, their relationship dynamics, their HIV risk behaviour, their beliefs and attitudes about antiretroviral therapy (ART) and their views of the community perceptions of discordance and treatment for HIV.

RESULTS

Findings revealed that at baseline there were multiple complex explanations and interpretations about discordance among discordant couples and their surrounding community. Shifts in beliefs and attitudes about discordance, HIV risk reduction and ART over time were enabled through re-testing negative members of discordant couples and repeat counselling but some beliefs remain solidly embedded in cultural imperatives of the importance of childbearing as well as culturally determined and enforced gender roles.

CONCLUSIONS

Interventions that aim to target discordant couples must embrace the complex and dynamic understandings of HIV diagnosis and treatment in context of fluid relationships, and changing beliefs about HIV risk and treatment.

Determinants of fertility desire among married or cohabiting individuals in Rakai, Uganda: a cross-sectional study

BACKGROUND

Recent trends in fertility rates indicate declines in total fertility rate (TFR) in some sub-Saharan African countries. However, countries such as Uganda continue to have a persistently high TFR partly attributed to strong preferences for large family sizes. We explored the factors that influence fertility desire among married or cohabiting individuals in Rakai, a rural district in southwestern Uganda.

METHODS

This cross-sectional study of fertility desire (desire to have another child) was nested in a cluster-randomized demand-creation intervention trial for the promotion of couples' HIV counseling and testing uptake among married or cohabiting individuals that was conducted in Rakai district between March 1 and April 30, 2015. A total of 1490 married or cohabiting individuals, resident in three study regions with differing background HIV prevalence, were enrolled into the study. Data were collected on socio-demographic, behavioral and fertility-related characteristics. We used a modified Poisson regression model to generate prevalence ratio (PR) as a measure of association for factors that were independently associated with fertility desire. We adjusted for clustering at community level and used STATA version 14.0 for all analyses.

RESULTS

Overall, fertility desire was high (63.1%, n = 940); higher in men (69.9%, n = 489) than women (57.1%, n = 451). More than three-quarters (78.8%, n = 1174) had 3+ biological children while slightly more than two-thirds (68.5%, n = 1020) reported an ideal family size of 5+ children. Only 30% (n = 452) reported that they had attained their desired family size. After adjusting for potential and suspected confounders, the factors that were negatively associated with fertility desire were: age 30-39 (adjusted prevalence ratio [aPR] = 0.82, 95% CI: 0.78, 0.86) and 40+ years (aPR = 0.65, 95% CI: 0.60, 0.71); having six or more biological children (aPR = 0.88, 95% CI: 0.80, 0.97); being HIV-positive (aPR = 0.86, 95% CI: 0.78, 0.95) and ever use of any family planning methods (aPR = 0.93, 95% CI: 0.87, 0.99). Being male (aPR = 1.19, 95% CI: 1.07, 1.33); having primary education (aPR = 1.21, 95% CI: 1.01, 1.44) and having not yet attained the desired family size (aPR = 4.34, 95% CI: 3.50, 5.38) were positively associated with fertility desire.

CONCLUSION

Having not yet attained one's desired family size, being male and having primary education were positively associated with fertility desire in this population. Targeting individuals who have not yet attained their desired family size, men and less educated individuals with fertility regulation interventions may help to reduce fertility desire in this population.