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

"First was to sit down and bring our minds together". A qualitative study on safer conception decision-making among HIV sero-different couples in Zimbabwe

Decision-making on childbearing and safer conception use in HIV sero-different couples involves an intricate balance of individual desires and perceived HIV acquisition risk. This paper addresses an important knowledge gap regarding HIV sero-different couples' considerations and the relationship and power dynamics involved when deciding to use a safer conception method. Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples, who exited the SAFER study - a pilot study assessing the feasibility, acceptability and cost-effectiveness of a safer conception programme for HIV sero-different couples in Zimbabwe. All couples in SAFER were provided with a choice of safer conception methods and were followed for up to 12 months of pregnancy attempts and 3 months following pregnancy. While couples generally perceived their safer conception discussions to be easy and consensus-driven, the decision-making process also involved complex gender dynamics and trade-offs in relationship power, which resulted in differing interpretations of what constituted a joint or shared couple decision. Participants regarded effective couple communication as an essential component of and precursor to good safer conception conversations and requested additional training in couple communication. Couples relied on information from healthcare providers to kickstart their safer conception discussions. Safer conception programmes should address relationship power imbalances, promote effective couple communication and offer healthcare provider support to enable HIV sero-different couples to make informed choices about conception in a manner that upholds their safety and reproductive autonomy.

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.

Rural-Urban Migration, Childbearing Decision-Making, Fertility and Contraceptive Perspectives of Street Adolescents and Youth in Kampala, Uganda

Introduction

This paper aims to describe and assess social demographic factors associated with childbearing decision-making, fertility and contraceptive intentions among street adolescents and youth in Kampala, Uganda while considering rural-urban migration as an explanatory factor.

Materials and Methods

A cross-sectional survey of 513 adolescents and youth aged 12–24 years self-identifying as street adolescents and youth were interviewed with a structured questionnaire in 2019. Street adolescents and youth who migrated from other rural districts to Kampala were compared with those from the city. Logistic regression was performed to assess associations between the independent factors and personal childbearing decision-making, fertility and contraceptive intentions.

Results

Overall, 80.31% of the street adolescents and youth had a rural-urban migration experience. Fifty six percent (56.32%) of the street adolescents and youth made personal childbearing decisions, 94.15% expressed intentions to have children in the future and 42.88% expressed intentions to use contraceptives in the future. Intentions to use contraceptives were significantly higher among males (58.75%) than females (20.00%), and higher among migrants (65.91%) compared to non-migrants (34.09%). Contraceptive intentions were positively associated with self-perceived permanent residential status (aOR = 10.26, 2.70–39.08), intra-urban mobility (aOR = 4.99, 95%CI 1.50–6.59) and intentions to migrate to other towns within the country (aOR = 5.33, 95%CI 1.59–17.80). Being married (aOR = 0.13, 95%CI 0.02–0.85), a large shelter population size (aOR = 0.13, 95%CI 0.03–0.63) and having repeat migrations between the city and home district (aOR = 0.23, 95%CI 0.05–0.94), including migration-associated challenges reduced the odds of street youth's personal childbearing decision-making, while belonging to a social support group increased the odds of childbearing decision-making. We found no significant association between social demographic characteristics and fertility intentions.

Discussion

Factors that influenced personal childbearing decision-making and contraceptive intentions among street adolescents and youth in Kampala operate mainly at the interpersonal and community levels, with marital status, shelter population size, rural-urban migration and its associated challenges associated with childbearing decision-making. Interventions to promote childbearing decision-making and contraceptive use among street adolescents and youth should take into consideration their migration and intra-urban mobility patterns.

Factors associated with pregnancy uptake decisions among seropositive HIV people receiving antiretroviral therapy in sub‐Saharan Africa: A systematic review

Aim

This study determined the factors associated with pregnancy uptake decision among seropositive HIV people receiving antiretroviral therapy in sub‐Saharan Africa.

Design

Systematic review.

Methods

The population, intervention, comparison and outcomes framework was adopted to search for literature after a scoping review using the preferred reporting items for systematic reviews and meta‐analyses guidelines adopted in searching, and screening articles from four databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and Google scholar) to find 12 articles suitable for this study.

Results

Motivators of pregnancy uptake among HIV‐positive women include desire to have children, knowledge about PMTCT, cultural duty for married women to have children, and household income. Demotivating factors included the modern method of contraception and burden associated with pregnancy.

Conclusion

There is a need to improve on services that reduce conception‐related risks especially for women who choose to conceive and to incorporate fertility‐related counselling into HIV treatment services.