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Fertility Desires Among HIV-Infected Men and Women in Los Angeles County: Client Needs and Provider Perspectives

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Abstract and Figures

Combination antiretroviral therapy for persons living with HIV/AIDS (PLHA) has extended life expectancy, and enabled PLHA to live productive lives that can include having children. Despite calls to address childbearing for PLHA there has been limited attention to developing safe conception programs. This research sought to assess the childbearing desires of PLHA and the experiences of health care providers serving this population. Research entailed a brief cross-sectional client survey given to HIV-infected men and women over age 18 at two Los Angeles County clinics administered over an 8-week period. Focus group discussions were conducted with providers at each clinic site. Although 39 % of the 93 clients surveyed reported a desire to have children, two-thirds of clients had not discussed their desires, or methods of safe conception, with providers. Providers reported challenges in providing safe conception services in resource poor settings where clients cannot afford assisted fertility services and in the absence of national, state, or county guidelines for safe conception. They noted complex and varied client circumstances and a critical need for provider training in safe conception. Guidelines that focus on safe conception and harm reduction strategies as well as the legal ramifications of counseling on these practices are needed. HIV providers need training and patients need educational tools and workshops informing them of the risks, challenges, and options available to them and their partners to safely conceive and bear an HIV-negative child.
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Fertility Desires Among HIV-Infected Men and Women
in Los Angeles County: Client Needs and Provider Perspectives
Deborah Mindry Glenn Wagner Jordan Lake
Amber Smith Sebastian Linnemayr
Molly Quinn Risa Hoffman
Published online: 5 May 2012
Springer Science+Business Media, LLC 2012
Abstract Combination antiretroviral therapy for persons
living with HIV/AIDS (PLHA) has extended life expec-
tancy, and enabled PLHA to live productive lives that can
include having children. Despite calls to address child-
bearing for PLHA there has been limited attention to
developing safe conception programs. This research sought
to assess the childbearing desires of PLHA and the expe-
riences of health care providers serving this population.
Research entailed a brief cross-sectional client survey
given to HIV-infected men and women over age 18 at two
Los Angeles County clinics administered over an 8-week
period. Focus group discussions were conducted with
providers at each clinic site. Although 39 % of the 93
clients surveyed reported a desire to have children, two-
thirds of clients had not discussed their desires, or methods
of safe conception, with providers. Providers reported
challenges in providing safe conception services in
resource poor settings where clients cannot afford assisted
fertility services and in the absence of national, state, or
county guidelines for safe conception. They noted complex
and varied client circumstances and a critical need for
provider training in safe conception. Guidelines that focus
on safe conception and harm reduction strategies as well as
the legal ramifications of counseling on these practices are
needed. HIV providers need training and patients need
educational tools and workshops informing them of the
risks, challenges, and options available to them and their
partners to safely conceive and bear an HIV-negative child.
Keywords Safe conception HIV United States
Fertility intentions PLHA
Introduction
Combination antiretroviral therapy (ART) for persons liv-
ing with HIV/AIDS (PLHA) has significantly extended life
expectancy, and enabled men and women to live active and
productive lives that can include having and raising chil-
dren [14]. The availability of ART and the advances in
prevention-of-mother-to-child transmission (MTCT) have
resulted in more HIV-infected women electing to carry
pregnancies to term [1]. In the United States, the estimated
number of births from HIV-infected mothers in 2006 was
8,700, a 30 % increase over the number of estimated births
in 2000 [1]. Studies have reported between 26–40 % of
PLHA in the United States desire a child in the future
[47]. Despite the described needs of HIV-infected patients
and calls to address the fertility needs of PLHA in the
United States, little has been done in clinical settings to
address the risk of horizontal transmission in serodiscor-
dant couples desiring pregnancy, or to explore a couple- or
family-centered approach to harm reduction for people
with HIV who want to have children.
The bulk of research and clinical interventions surrounding
childbearing have focused on the fertility needs, desires, and
risks to HIV-infected women and the prevention of MTCT
D. Mindry (&)
Center for Culture and Health, Department of Psychiatry
and Behavioral Sciences, NPI-Semel Institute for Neuroscience,
University of California, 760 Westwood Plaza, P.O. Box 62,
Los Angeles, CA 90024-1759, USA
e-mail: dmindry@ucla.edu
G. Wagner A. Smith S. Linnemayr
RAND Institute, Santa Monica, CA, USA
J. Lake M. Quinn R. Hoffman
Division of Infectious Diseases and Center for Clinical AIDS
Research and Education, David Geffen School of Medicine
at University of California, Los Angeles, CA, USA
123
Matern Child Health J (2013) 17:593–600
DOI 10.1007/s10995-012-1035-6
[14]. However, the fertility desires and needs of HIV-infec-
ted men and/or serodiscordant couples, have received limited
attention [68]. Sauer et al. [6,7]atColumbiaUniversity
have most actively investigated the issues confronting men
living with HIV and the potential of assisted reproductive
services to meet their needs. It is increasingly apparent that
there is a need to expand reproductive health services for
HIV-infected individuals and/or serodiscordant couples, to
prevent HIV transmission to a seronegative partner as they
seek to conceive, ensuring appropriate HIV care to optimize
individual health and to prevent MTCT [9].
We report the results of a survey of HIV-infected men
and women in two Los Angeles County community clinics.
This study sought to assess the extent to which men and
women living with HIV desire to have children, whether
desire is associated with the HIV status of the partner, and
to assess the perceived availability of reproductive health
services to assist HIV clients in safe conception and
childbearing. We also report findings from focus groups
with HIV providers regarding perceived challenges to
offering support and services to clients who desire children
with a view to preventing horizontal transmission of HIV.
Methods
Participants and Setting
This study was conducted at the Valley Community Clinic
(VCC) and the To Help Everyone (THE) Clinic, in Los
Angeles County, California. Both clinics provide HIV care
to underserved populations; the majority of patients are
enrolled in either Ryan White or Medi-Cal insurance pro-
grams. The study consisted of (1) a brief cross-sectional
survey for adult HIV clients, and (2) focus group discus-
sions with HIV providers at each of the clinics. The
anonymous survey was distributed to all clients over age 18
who attended a weekly clinic visit over an 8-week period.
No compensation was provided for the survey, which
took about 5 min to complete. The client survey (see
‘‘ Appendix’) consisted of 15 questions related to demo-
graphics (age, gender, presence of any children), relation-
ship status (including gender and HIV status of partner),
and fertility desires. Fertility desires were measured in
response to a two-part question: ‘‘Do you wish to have
a/another child?’’ With a follow up question to those who
responded ‘‘no’’: ‘‘Would your desire to have a/another
child change if you knew you could have a child with
limited risk of transmitting HIV to your partner and the
child?’’ to ensure that we would capture those individuals
who would consider having children if they could do so
safely. Respondents who answered ‘‘yes’’ to either question
one or two above were categorized as having ‘‘fertility
desires’’ in the binary variables used in the analysis; these
individuals were then asked questions with regard to
communication with providers about their fertility desires,
and knowledge of and access to reproductive health ser-
vices to promote safe childbearing (Table 1).
Providers (physicians, nurses, counselors, case manag-
ers) at both clinics were invited to participate in a site-
specific focus group. These discussions focused on pro-
viders’ perceptions and experiences regarding HIV clients’
reproductive health needs, their training experiences per-
taining to reproductive needs of PLHA, their knowledge of
available resources to meet client needs, and the challenges
they face in assisting PLHA to conceive and bear children.
The protocol was approved by the RAND Institutional
Review Board (IRB), which was deferred to by the UCLA
IRB as indicated by a joint agreement between the two
IRBs for collaborative studies.
Data Analysis
Descriptive statistics were used to examine frequency
distributions of key variables. Independent ttests (two-
tailed) were used to examine continuous variables in rela-
tionship to the binary indicator of fertility desire, while v
2
tests were used for categorical variables. Logistic regres-
sion analysis was performed to assess multivariate corre-
lates of having fertility desires. Independent variables
inserted into the model included age, gender, relationships
status and whether or not the patient had any children. The
qualitative data was analyzed using a grounded theory
approach which codes data according to common themes
and key concepts. The themes that emerged in the inter-
views were used to index the data using topical codes, also
called descriptive codes, in order to identify critical issues
related to the delivery of assisted reproductive services to
PLHIV.
Results
Patient Survey Results
The survey results was completed by 93 clients (Table 1).
Data on the number of patients approached to participate
were not collected, but site coordinators estimate that
approximately 65 % of patients at VCC completed the
brief survey while at THE approximately 75 % of clients
completed the survey. Two-thirds (68 %; n=63) of the
sample was male, and the mean age was 42 years
(SD =10.5; range: 23–72). Forty-six percent of respon-
dents (n=43) reported being in a relationship, of whom
38 % (14/37; 6 had missing data) had a same sex partner
and 63 % (26/41; 2 had missing data) had a partner whose
594 Matern Child Health J (2013) 17:593–600
123
HIV status was negative (n=20) or unknown (n=6).
The sample is generally reflective of the client populations
at each site.
Twenty-six percent (n=23) of clients responded ‘‘yes’
to the question, ‘‘Do you wish to have a/another child?’
But in a follow up question to those who responded ‘‘no’
to this question, another 13 % (n=12) affirmatively
responded to the question, ‘‘Would your desire to have
a/another child change if you knew you could have a child
with limited risk of transmitting HIV to your partner and
the child?’ Hence, a total of 39 % (n=35) of participants
expressed having fertility desires; however, only three
indicated they were actively trying to have a child. Among
those with fertility desires, 49 % (17/35) did not have any
children, compared to 58 % (33/57) of the clients who did
not have fertility desires (p=.38; 1 case had missing
data).
Men (39 %) were as likely as women (38 %) to express
a desire to have children (p=.86). Clients who wanted
a/another child were younger (mean age =35.5 years)
than clients who did not (mean age =46.1; p=.000);
among those aged 20–29, 79 % indicated a desire to have
a/another child, compared to 48 % in the 30–39 age group,
30 % in those aged 40–49, and only 11 % among those 50
or older (p=.000). Just over half of participants in a
relationship (54 %; 23/43) reported a desire to have
a/another child, compared to only 25 % (12/36) of those
who were single (p=.005). Among the clients in a rela-
tionship, the association between fertility desires and
partner HIV status was not statistically significant
(p=.50), although a slightly lower percentage of clients
with an HIV-positive partner wanted to have a/another
child (47 %; 7/15) compared to 58 % (15/26) to those with
an HIV-negative or unknown status partner. In logistic
regression analysis, age was the only significant indepen-
dent correlate of fertility desires (OR =0.87; 95 % CI
0.81–0.93; p=.000), while being a parent (OR =2.76;
95 % CI 0.82–9.28; p=.10) and relationship status
(OR =2.41; 95 % CI 0.81–7.24; p=.12) were margin-
ally related; gender had no relationship to fertility desires
(OR =0.95; 95 % CI 0.33–2.69; p=.92).
The subgroup of participants who reported a desire to
have a/another child was asked about the support and
services available to them to have children safely. When
asked whether there are methods available to them to
ensure that they could conceive a child with limited risk of
transmitting HIV to their partner, only 25 % (n=8) said
‘yes’, whereas 6 % (n=2) said ‘no’ and 69 % (n=22)
said they ‘did not know’. Additionally, 43 % (n=13) said
that ‘yes’ their doctor or nurse was able to provide them
with the services and assistance they need to safely have a
child, while 7 % (n=2) responded ‘no’ and 50 %
(n=15) indicated they ‘did not know’ whether their
providers could offer these services. Over two-thirds
(70 %, n=23) said that they had not talked to their pro-
vider about how to have a child safely; however, 64 %
(n=21) said that they would like to talk to their provider
about their desire to have a child, and 74 % (n=23) felt
that their provider would support their desire to have a
child.
Table 1 Characteristics of HIV-positive clients by desire to have a/another child
Characteristics Total (N=93) Desire a/nother child
(N=35)
Do not desire a/nother child
(N=58)
Pvalue
Mean age
a
42.2 (SD: 10.5; range: 23–72) 35.5 (SD: 8.5) 46.1 (SD: 9.5) .000
20–29 years 14 11 (79 %) 3 (21 %) .000
30–39 years 23 11 (48 %) 12 (52 %)
40–49 years 31 9 (29 %) 22 (71 %)
50?years 22 2 (9 %) 20 (91 %)
Male
b
64/90 (71 %) 24/34 (71 %) 40/56 (71 %) .932
In relationship
c
43/91 (47 %) 23/35 (66 %) 20/56 (36 %) .005
Same sex relationship
d
14/37 (38 %) 5/20 (25 %) 9/17 (53 %) .081
Sero-negative or status unknown
partner
e
26/41 (63 %) 15/22 (68 %) 11/19 (58 %) .495
Do not have child/ren
f
50/92 (54 %) 17/35 (49 %) 33/57 (58 %) .383
a
Three respondents had missing data regarding age
b
Three respondents had missing data regarding sex
c
Two respondents had missing data regarding relationship status
d
Six respondents had missing data regarding sex of partner
e
Two respondents had missing data regarding partner HIV status
f
One respondent had missing data regarding status of having children
Matern Child Health J (2013) 17:593–600 595
123
Provider Focus Groups
Five providers participated in the focus group at THE, and
three participated at VCC. Each group was comprised of at
least one physician, one case manager, and one nurse or an
additional case manager. The themes that emerged from
the provider focus groups discussions were: provider
knowledge related to HIV and reproductive health, client
needs, and resources; provider attitudes related to HIV
clients’ desires to have children and experiences of non-
HIV provider attitudes toward HIV-infected clients; pro-
vider needs related to availability of services, training, and
knowledge regarding reproduction in the context of HIV.
In the focus group discussions, providers noted that in
the early phase of learning about their HIV status clients
are assimilating the news and are not usually asking
questions about having children. Providers believed it was
more effective to discuss future childbearing with clients
once they have adjusted to their diagnosis. They noted that
during initial intake and counseling, it can be useful to
mention options for future childbearing to patients as a
topic for discussion when ready. They noted that it was
necessary for providers to raise these issues since many
clients assume that they cannot or should not have children
if they are HIV-infected.
Providers noted a great deal of complexity in the cir-
cumstances of clients expressing a desire for children. The
majority of clients at both clinics are men. Some of these
men are in heterosexual relationships. Yet others are con-
currently in sexual relationships with both women and
men. A final category of male clients are those in exclu-
sively same sex relationships. Providers noted that cir-
cumstances and needs are extremely varied given that men
in all 3 categories may express a desire for a biological
child. One provider reported that,
One of the clients today said, ‘‘Well, I’m gay but my
girlfriend, one of my closest friends, wants me to be
[the sperm donor for her]—she’s gay too, and she
wants to have a baby. So, she wants me to be the
father. But she doesn’t know I’m HIV positive. So,
can you help me try to figure that out?’’ (August 4,
2010).
Some heterosexual female clients also express a desire to
have a child but providers noted that most women in their
care already had children and in general clients (both male
and female) who already have children are less likely to
express a desire to have another child.
Providers noted when clients raise the issue of having
children one of their primary concerns is to avoid HIV
transmission to the child. Additionally, providers noted that
‘They [clients] also don’t want to ask and risk being told
no [they cannot have children]’’ (June 10, 2010). They
noted that it is extremely challenging to meet the needs of
couples when the HIV-infected client has not disclosed
their status to their partner. One provider noted,
I’ve had a couple of clients that are interested in
having kids but they want to know—and their part-
ner, or soon-to-be partner is negative—but they want
to know, how can they have kids without disclosure.
Like, do they have to disclose? That’s a big issue.
(August 4, 2010).
Providers expressed discomfort in working with male
clients who desired a child but were either unwilling to
disclose their status to their partner (sometimes out of
concern not only of HIV stigma but also in instances where
men were bisexual, out of fear of disclosure of having
concurrent male sexual partners) or had partners who were
unwilling to test or to come in for counseling. There were
two reported instances of male clients seeking provider
assistance to safely conceive a child to avoid infection of a
negative female partner and to the child. In these instances
the provider was able to work successfully with the
individual and when necessary with the couple to ensure a
safe conception and birth of a child that was uninfected.
Providers at both clinics noted that working with clients
in resource poor settings was additionally challenging
given the limited economic circumstances of the clients
and limitations in public medical assistance programs to
cover costs associated with assisted fertility services (such
as sperm washing and intrauterine insemination). As one
provider stated:
There is a problem with trying to provide appropriate
care. Fertility specialists are a cash business. These
services are not available for free. Our clients don’t
pay anything when they come here. They have to be
prepared to pay for these services, and they cannot
usually afford them. There is often a longing for
children but not an active plan. However, I have a
client now who wants to have a child. He has a plan
and he is saving up to pay for the sperm washing and
fertility services. Every time he comes in we check
how he is doing with his plan. (June 10, 2010)
Some providers had found ways to refer clients to less
expensive fertility services, but clients still had to pay for
some of these services and costs are often unpredictable.
One provider reported that ‘‘we referred a patient and it
was prohibitively expensive. The discounted price was,
like, $4,000 and he came back and said, ‘‘I can’t afford
that. What do I do next?’’’’(August 4, 2010). Providers felt
the challenges of working in resource-poor settings are not
receiving adequate attention. One provider said,
596 Matern Child Health J (2013) 17:593–600
123
And it feels, from a provider’s standpoint, sort of
suboptimal. And I think what’s interesting about our
setting is that we’re resource-rich, really, as a coun-
try, but we are resource-poor and most HIV care is
resource-poor, you know, because that’s who’s HIV
infected. (August 4, 2010).
Providers also noted a great deal of misinformation among
clients. They reported, for example, instances in which
women who wanted to conceive a child thought that they
simply needed to seek out an HIV-negative partner in order
to prevent HIV transmission to the child. In another
instance a provider reported on a heterosexual male client’s
lack of information regarding methods for prevention of
HIV transmission:
We had one client who had a child with a previous
partner. The child was born HIV negative. He then
assumed everything would be fine when he was with
his new partner. He was not aware of the process that
his first partner went through to ensure that their child
was born negative. Because he did not know the
procedure they did not get counseling and his second
child with his new partner was born HIV positive.
(June 10, 2010).
Another problem providers confront is that female clients
often approach them late in the process of fertility planning:
They are not aware of treatment to avoid transmission
of HIV to their child. They usually come to us when
they are already pregnant. They are diagnosed for
HIV late (sometimes tested because of the preg-
nancy), and then we have to deal with the problems.
(June 4, 2010).
In addition, providers noted two issues in their own training
and practice that impacted their ability to be proactive with
clients’ childbearing needs: (1) provider training in repro-
ductive health services for PLHA was absent or sparse at
best; and (2) provider decision making is not supported by
county, state or national guidelines for PLHA who desire
genetic children. Providers discussed the gaps in their
training. One provider said:
I think the problem is in the medical community. I
don’t think there is a formal training for this [helping
PLHA conceive safely]. I’ve never seen a workshop
about it; I’ve never seen a specific kind of educational
section about it. I think you’d have to—there’s
training in, obviously, reproductive endocrinology
and in vitro fertilization in that department with the
Obstetrics and Gynecology area. And then, obvi-
ously, there’s HIV [training]. But I don’t think any-
one has ever brought those two together. (August 4,
2010).
Providers noted that obstetrics and gynecology providers
do not generally have significant training in HIV, and may
be reluctant to provide even basic services to PLHA. One
provider related an instance in which an obstetrician who
discovered through testing that his pregnant client was
HIV-positive called in a security guard while he delivered
the news to her. The client reportedly left and disappeared
from care: ‘‘So, we didn’t know where this woman was,
pregnant with twins and HIV positive, 20 weeks.’’ (August
4, 2010).
Providers were also reluctant to counsel clients given a
general lack of confidence about risks of HIV transmission
while trying to conceive. A provider noted,
I don’t know enough about it to encourage it
[unprotected sex to conceive]. HIV response in dif-
ferent body compartments is different. If viral load is
low in blood that does not mean it is low in semen or
in other bodily fluids. Also every patient will be
different. You really need a reproductive endocri-
nologist to help make recommendations. You need
information that is matter of fact. (June 10, 2010).
The provider went on to say,
even if it is a 1 % risk, I can’t recommend they
take that risk. I really don’t know how you would
predict risk. It is stressful to me to tell them, ‘‘go
ahead you have a low risk [of transmitting HIV to
your partner].’’ (June 10, 2010).
Providers were concerned about the ethical challenges of
counseling clients in the absence of clear guidelines
developed from evidence-based research.
You always individualize your treatment for each
patient, but you always want evidence to back it up.
(August 4, 2010).
Providers emphasized the need for training and guidelines
for providers as well as educational information for clients.
Discussion
There is an increasing need to address the fertility desires
and intentions of PLHA. Although 39 % of clients in our
study reported a desire to have children most were unaware
of available methods to increase the safety of conception,
and most had not discussed such methods or their desires
for children with providers. Burr et al. [3] notes there is a
desperate need for preconception counseling for HIV-
infected men and women and for national guidelines on
assisted reproductive technologies for HIV-infected sero-
discordant and seroconcordant couples seeking to conceive
children. Our data support this conclusion, particularly the
Matern Child Health J (2013) 17:593–600 597
123
need for specific information and/or guidelines to support
providers in steering patients through the process, to reduce
harm during peri-conception, optimize individual health,
and prevent vertical transmission.
While a variety of organizations provide guidance on
addressing general approaches to pre-conception coun-
seling for couples where one or both partners have HIV
infection (American Congress of Obstetricians and
Gynecologists, the AIDS Education and Training Centers
National Resource Center, and the USPHS Perinatal
Guidelines 2010 [15], among others), there is a clear need
for much more specific and detailed recommendations for
use by clinicians working with HIV-infected men and
women of reproductive age, and a need for materials
geared towards clinicians with primary care backgrounds
(as compared to obstetrics and gynecology or reproduc-
tive endocrinology), A broad working document from the
CDC or other national government agency would be
welcome; however, any document will likely have to be
accompanied by state-level guidance addressing local
regulations that may dictate interventions. Recommenda-
tions should be provided with consideration of the costs
associated with assisted reproductive services to PLHA in
the US, where the majority of HIV care occurs in
resource-poor settings. Guidelines should include infor-
mation on inexpensive harm reduction strategies such as
timed unprotected intercourse during ovulation, sperm
washing (for positive male/negative female) and self-
insemination (for positive female/negative male). Harm
reduction strategies can also include identifying and
treating sexually transmitted infections including genital
herpes simplex virus, and circumcision of an HIV-nega-
tive male partner.
Like Sauer [7], we found that provider concerns
include issues related to the potential liability associated
with discussing fertility options for PLHA, particularly in
the absence of national guidelines [9]. Therefore, as
consideration is given to the development of guidelines,
perspectives of lawyers well-versed in fertility rights will
be needed, to clarify the potential liability associated with
reproductive health counseling for HIV-infected clients.
The South African HIV Clinicians Society recently pub-
lished a ‘Guideline on Safer Conception in Fertile HIV-
Infected Individuals and Couples’ [10], which serves as a
good model for the type of guidance needed in the
United States. Our group is working with other collabo-
rators on a similar document for use in the greater Los
Angeles area.
The NIAID-funded HPTN 052 study showed that ART
use in serodiscordant couples was associated with a 96 %
efficacy in reducing transmission of HIV to an uninfected
partner [11]. This data, although preliminary, suggests a
promising harm reduction strategy towards meeting the
fertility needs of serodiscordant couples. However, to
maximize efficacy of ART as prevention of transmission
from an HIV-positive individual to a negative partner,
individuals must engage in care and adhere daily to anti-
retroviral medication regimens, a not insubstantial chal-
lenge for many patients. Overall, the complement of
fertility services need to be delivered within a larger
framework of HIV care including identifying HIV-infected
men and women, facilitating entry to care, and retaining
people in care long-term.
While ART for prevention of transmission is a promis-
ing strategy for use by HIV-infected individuals, the use of
pre-exposure prophylaxis (PrEP) is an emerging strategy
for use by the HIV-uninfected partner to prevent HIV
acquisition. PrEP has proven a successful strategy in men
who have sex with men with efficacy associated strongly
with level of medication adherence [12]. A study of PrEP
in women was recently halted for futility, with further
analysis showing that less than half of women in the study
were adherent to medications, suggesting that adherence
may be the major barrier to the success of this strategy for
both men and women [13]. Two other studies, Partners
PrEP and TDF2, have also shown efficacy in African het-
erosexual populations, yet optimal use and adherence
issues of PrEP for conception remains unclear [14]. Despite
a lack of data, clients may turn to the use of unproven
strategies for fertility assistance due to lack of awareness or
poor understanding of the available options and evidence
base. There is an urgent need for research on the attitudes
and knowledge of safe conception and PrEP among HIV-
negative partners of HIV-infected persons, especially in
HIV-negative female partners of HIV-infected men.
This study is just a beginning in addressing the needs of
providers and their HIV-infected clients. Our study was
limited to gathering brief survey data from clients as well
as focus groups with a small number of providers. We did
attempt to conduct in-depth interviews and focus groups
with clients, but we encountered numerous challenges
including clients’ fears of their HIV status being revealed
in the context of focus groups, and reluctance to take time
away from work to participate. Examination of these issues
with larger samples of clients and providers, from diverse
settings and including the partners, are needed to further
our understanding of the reproductive health needs of
PLHA, and the needs of HIV providers who are in a
position to best address these needs.
Acknowledgments We would like to thank clinic leadership as well
as the staff at the Valley Community Clinic (VCC) and the To Help
Everyone (THE) Clinic for their support and assistance with the
study. We also gratefully acknowledge the patients who participated
in the study.
598 Matern Child Health J (2013) 17:593–600
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Appendix: Survey on Fertility Desires
and Reproductive Health Services
Thank you for completing the survey. If you have had a
child since testing HIV1, or if you are currently trying
to have a child or have desires to have a child, and you
would be willing to participate in a focus group with
others HIV clients like yourself, please inform the clinic
staff member who gave you this survey or your pro-
vider of your interest. Please note that your participa-
tion in this focus group is completely voluntary.
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... In HIC, seven studies were conducted in the US (87.5%) and one in Switzerland [64]. Six studies were quantitative (75%), and two were mixed methods studies [65,66]. Seven studies (87.5%) had a cross-sectional design, one of which was a retrospective chart review [6]. ...
... In the three studies that included both members of the dyad, the man was the index partner [6,65,67]. In two studies, this information was not reported [64,66]. Almost all studies (7/8; 87.5%) reported how the fertility desires/intentions were assessed, of which four clearly reported a dichotomous response choice [6,66,68,69] and one mentioned that responses greater than zero represented fertility desires/intentions [25]. ...
... In two studies, this information was not reported [64,66]. Almost all studies (7/8; 87.5%) reported how the fertility desires/intentions were assessed, of which four clearly reported a dichotomous response choice [6,66,68,69] and one mentioned that responses greater than zero represented fertility desires/intentions [25]. One study did not report any information about the question specifically assessing the outcome of interest [64]. ...
Article
Full-text available
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.
... Inadequate information leads to unequal access to family planning options, in particular fertility care for PLHIV (Goggin et al., 2018). Notwithstanding, many PLHIV regard the opinion of their HCP as important in making fertility decisions (Mindry et al., 2013) though they seldom discuss fertility decisions with them (Abbawa et al., 2015). According to UNAIDS, many women living with HIV (WLHIV) report no or limited knowledge of/access to fertility care services (UNAIDS Global Report, 2003) and HIV-infected men opine that providers think they only have sex with men and are not interested in having children (Mindry et al., 2013). ...
... Notwithstanding, many PLHIV regard the opinion of their HCP as important in making fertility decisions (Mindry et al., 2013) though they seldom discuss fertility decisions with them (Abbawa et al., 2015). According to UNAIDS, many women living with HIV (WLHIV) report no or limited knowledge of/access to fertility care services (UNAIDS Global Report, 2003) and HIV-infected men opine that providers think they only have sex with men and are not interested in having children (Mindry et al., 2013). With increased call for safer conception programs for PLHIV (Hancuch et al., 2018), health care providers particularly in countries with low resources are urged to become more informed about managing PLHIV's expectations to have families (Mindry et al., 2016). ...
Article
Increased life expectancy among persons living with HIV (PLHIV) has increased the desire for parenthood. It is therefore important that PLHIV and health care providers (HCPs) are aware of the available assisted reproduction services (ARS) for PLHIV facing infertility or unsuppressed viremia. Through secondary data analysis we identified PLHIV who were actively trying to conceive and their knowledge of ARS. As specialized fertility care for PLHIV is managed by Obstetrician/Gynecologists (Ob/Gyns), they were surveyed regarding their attitudes towards working with PLHIV and their awareness and knowledge of ARS with a self-administered questionnaire. In this cross-sectional study, 251 PLHIV and 102 Ob/Gyns were recruited and interviewed using a semi-structured questionnaire. Although most Ob/Gyns (81%) reported being supportive of PLHIV having children, 85% counseled against pregnancy, particularly persons in HIV serodifferent relationships. Significantly more PLHIV under 40 years compared to those over 40 years had heard about ARS (59% vs. 43%, p = .007). Ob/Gyns were more knowledgeable of expensive ARS, while PLHIV’s knowledge was more restricted to cheaper more accessible ones. In conclusion Ob/Gyns knowledge gaps and underlying stereotypes may present barriers to PLHIV’s uptake of ARS. Additionally, virologically unsuppresed persons in HIV serodifferent relationships may be vulnerable as Ob/Gyns were less supportive of them.
... At baseline, around 20% of women were unsure whether they wanted to become pregnant in the future. A study published in 2013 of men and women living with HIV in Los Angeles found that 13% of study participants who responded "no" to the survey question "do you wish to have a/another child?", also responded "yes" when asked "Would your desire to have a/another child change if you knew you could have a child with limited risk of transmitting HIV to your partner and the child" [36]. These results may reflect feeling inadequately informed to make pregnancy decisions given the changing reproductive landscape, particularly for women living with HIV [37][38][39][40][41][42]. ...
Article
Full-text available
Background Women with an undetectable viral load can become pregnant and have children with no risk of HIV transmission to their sexual partners and low risk of transmission to their infants. Contemporary pregnancy intentions of women living with HIV in Canada are poorly understood, evidenced by high rates of unintended pregnancy and low uptake of contraceptives. Methods We used longitudinal survey data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) to measure and compare pregnancy intentions (Yes vs No vs Unsure) at baseline, 18-months and 36-months follow-up (from 2013 to 2018) among women living with HIV of reproductive age (16–49 years) and potential. We used Sankey diagrams to depict changes in pregnancy intentions over time and multivariable logistic regression to examine the relationship between pregnancy intention within 2 years and subsequent pregnancy. Results At baseline, 41.9% (119/284) of women intended to become pregnant, 43.3% did not, and 14.8% were unsure. Across 36-months of follow-up, 41.9% (119/284) of women changed their pregnancy intentions, with 25% changing from intending to not intending to become pregnant and 13.1% vice versa. Pregnancy intentions were not strongly associated with subsequent pregnancy between baseline and 18-months (aOR 1.44; 95% CI 0.53, 3.72) or between 18 and 36-months (aOR 2.17; 95% CI 0.92, 5.13). Conclusions Our findings underscore the need for healthcare providers to engage in ongoing discussions with women living with HIV to support their dynamic pregnancy intentions.
... To optimally achieve these outcomes for WLWH, it is important for providers to proactively engage with patients about fertility desires and timing of childbearing and to facilitate PCC. Studies suggest that these discussions are not being initiated by either the provider or the patient (Finocchario-Kessler et al. 2010, 2012Gokhale et al. 2017;Mindry et al. 2013;Squires et al. 2011). Even when discussions are being initiated, the burden of communicating those desires is often placed on the patient, which can impact the timing and nature of the interaction (Tanner et al. 2018). ...
Article
Full-text available
Introduction This study assesses HIV provider views on the value of a checklist designed to assess patients’ preconception care (PCC) needs and guide implementation of PCC. Methods Ninety-two HIV providers in seven U.S. cities provided perspectives via an in-depth phone interview regarding a checklist to facilitate communication and referrals for PCC. A sub-sample of 27 providers shared feedback on a checklist designed for this purpose. Interview audio files were transcribed and uploaded to a web-based program supporting coding and analysis of qualitative data. Content analysis was utilized to identify key themes within the larger, a priori themes of interest. Feedback regarding the checklist was analyzed using a grounded theory approach to examine patterns and emergent themes across transcripts. Results Providers averaged 11.5 years of HIV treatment experience; over 80 percent were physicians (MD) or nurse practitioners (NP) and 76 percent were HIV/infectious disease specialists. The majority of providers were female (70%) and Caucasian (72%). Checklist benefits identified included standardization of care, assisting new/inexperienced providers, educational resource for patients, and aid in normalizing childbearing. Concerns included over-protocolizing care, interfering with patient-provider communication, or requiring providers address non-priority issues during visits. Providers suggested checklists be simple, incorporated into the electronic medical record, and accompanied with appropriate referral systems. Discussion Findings support a need for a checklist tool to assist in conversations about reproductive intentions/desires. Additional referral or innovative consultative services will be needed as more persons living with HIV/AIDS are engaged on the topic of childbearing.
... Lack of patient-provider communication about pregnancy has been seen among women living with HIV in other settings [6][7][8]40], however FSWs may be at greater risk pregnancy related complications [25,26]. The lack of patient-provider communication surrounding pregnancy in this study is concerning due to the high reported number of lifetime pregnancies, number of children and pregnancies that did not result in live births. ...
Article
Full-text available
Background: Health providers can play an important role in communication about pregnancy, particularly for women at increased risk for pregnancy complications, including female sex workers (FSWs) living with HIV. This study explored factors related to patient-provider communication about pregnancy among 253 FSWs living with HIV of reproductive age in Santo Domingo, Dominican Republic. Methods: A cross-sectional design was employed including structured socio-behavioral surveys. Data were analyzed utilizing bivariate and multivariate logistic regression. Results: Of the 253 FSWs living with HIV in this study, 95.7% had been pregnant at least once (median: 4; IQR: 3,6), 28.0% wanted more children and 36% reported a pregnancy after HIV diagnosis. Over half of participants (58.0%) reported having ever spoken to a health provider about pregnancy while living with HIV. Multivariate logistic regression found significant associations between having spoken to a health provider about HIV in pregnancy and a more positive perception of their provider (AOR: 2.0; 95% CI: 1.0, 2.5) and years since HIV diagnosis (AOR: 1.1; 95% CI: 1.0, 1.1). Participants were less likely to speak with a provider if they had a history of drug use (AOR: 0.4; 95% CI: 0.2, 0.9) or current alcohol use (AOR: 0.5; 95% CI: 0.3, 0.9). Conclusion: Findings highlight the importance of non-judgmental and tailored provider-initiated conversations surrounding pregnancy. Future research is needed to better understand how and when pregnancy communication is initiated, as well as the content of clinical care conversations, to address the reproductive health of FSWs living with HIV.
... In case people living with HIV desire to have children, counseling by their health care providers has critical role to assure planned pregnancies, and minimizing prevention of mother to child transmission [28]. However, in many settings a large majority of HIV-positive women who desire more children have not discussed about reproductive health and childbearing with their health care providers [29][30][31]. Besides, contraception strategy has also been evidenced by the world health organization as a key strategy to reduce new infant infections [32]. In Ethiopia, studies conducted so far indicated that fertility desire in women living with HIV ranged from 34 to 45% [33][34][35][36]. ...
Article
Full-text available
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. Electronic supplementary material The online version of this article (10.1186/s13104-019-4190-7) contains supplementary material, which is available to authorized users.
... Previous research has shown that fatherhood is a life-changing experience for the male population. 2 However, HIV research concerning reproductive health and family planning to date has focused mainly on women. 3 It is also evident that available studies on men have been disproportionately biased toward the perspective of heterosexual men. 4 Studies from the United States, Europe, and Africa [5][6][7][8] have postulated that a high proportion of men living with HIV in these countries want to have children. In addition, previous studies have identified several key factors influencing men living with HIV regarding their decision to have children. ...
Article
Full-text available
Men with HIV have highlighted the importance of understanding their fertility desires. However, most research has focused on women. We aimed (1) to develop a survey instrument to assess fertility desires and intentions among HIV-positive men and (2) to assess its face, content, and construct validity, as well as test-retest reliability and internal consistency. Principal component analysis was used for construct validity analysis in a sample of 60 men with HIV. The test-retest reliability and internal consistency were assessed using Spearman correlation and Cronbach α, respectively. The initial and the final version of the questionnaire consisted of 10 domains and 14 constructs. We found a one-component model for the 3 constructs analyzed and Cronbach α values were ≥.70. Test-retest statistic was stable with Spearman correlation >0.70. In conclusion, a reliable and valid questionnaire was developed for determining the fertility desires and intentions of men with HIV.
Article
Preconception care is an essential component of health, particularly among women and men living with HIV and can optimize medical and psychosocial outcomes. However, there is a paucity of data on this topic, especially when evaluating provider communication with male patients. We conducted a multi-site qualitative study in 7 cities in the United States (US) with 92 providers to assess their attitudes and practices regarding preconceptual counseling, safer conception, and preconception care with their patients living with HIV. Providers were contacted to schedule a phone interview. Recorded interviews were transcribed and coded for a priori and emergent themes. Providers reported infrequent communication with male patients with HIV about their reproductive plans and the use of safer conception, acknowledging they were more likely to initiate such communication with female patients. A small percentage of providers reported talking to all of their patients about reproductive options, including men having sex with men (MSM). Currently, there is no consensus or evidence-based guideline for the delivery of preconception care specific to men. Based on our results, we recommend that providers offer preconception care to all men as part of optimizing family planning and pregnancy outcomes; enhancing reproductive health; preparing men for fatherhood; and in the setting of HIV infection, preventing transmission to an uninfected partner.
Article
Reproductive and sexual health outcomes of adults with perinatal human immunodeficiency virus (PHIV) have not been well-characterized. This prospective cross-sectional study of 35 adult persons living with HIV (PLWH) from early life and 20 matched HIV-negative controls assessed quality of life, depressive symptoms, HIV transmission knowledge, and sexual/reproductive behaviors through self-report questionnaires. PLWH scored significantly worse than controls on depressive symptoms (p = 0.04) and two of six quality of life domains (p = 0.03, p = 0.0002). In contrast, PLWH scored significantly higher on transmission knowledge in the context of family planning (p = 0.002). PLWH were more likely to learn about sex from healthcare providers (p = 0.002) and were more confident in their sexual/reproductive health knowledge (p < 0.05). Both groups reported inconsistent condom use, but PLWH were more likely to have planned pregnancies (p = 0.005) and to share pregnancy planning with their partners (p < 0.05). Despite the challenges of living with a chronic stigmatized condition, adults with PHIV were knowledgeable about HIV transmission and family planning and demonstrated sexual practices and reproductive outcomes similar to age-matched controls. However, sub-optimal rates of viral suppression, inconsistent condom use, and the psychosocial impact of living with HIV continue to require the attention of healthcare provides for young adults with PHIV.
Article
Full-text available
Ninety years ago the isolation of insulin transformed the lives of people with type 1 diabetes. Now, models based on empirical data estimate that a 25-year-old person with HIV, when appropriately treated with antiretroviral therapy, can expect to enjoy a median survival of 35 years, remarkably similar to that for someone of the same age with type 1 diabetes. It is high time we normalised the lives of people living positively with HIV. This includes the basic human right to conceive and raise children. HIV-positive individuals may be in serodiscordant relationships or in seroconcordant relationships. As health care providers, it is our responsibility to ensure we understand the opportunities and risks of natural conception in these scenarios, so that we can help our patients to make informed decisions about their own lives. Most of all, it is our duty to make family planning in the setting of positive prevention as safe as we can. This includes informed decisions on contraception, adoption, fostering, conception and prevention of mother-to-child transmission. Some months ago a dedicated group of individuals, invited and sponsored by the Southern African HIV Clinicians Society, came together in Cape Town to devise guidance in this area, recognising that there are ideal strategies that may be outside the realm of the resource constraints of the public sector or health programmes in southern Africa. This guideline therefore attempts to provide a range of strategies for various resource settings. It is up to us, the providers, to familiarise ourselves with the merits/benefits and risks of each, and to then engage patients in meaningful discussions. All the above, however, is based on the premise and prerequisite that the subject of family planning is actively raised and frequently discussed in our patient encounters.Please find a link to the update of this guideline: http://sajhivmed.org.za/index.php/hivmed/article/view/399
Article
Full-text available
The success of combination antiretroviral therapies for the treatment of human immunodeficiency virus (HIV) has resulted in prolonged life expectancy (over 40 years from diagnosis) and an improved quality of life for people living with HIV. The risk of vertical HIV transmission during pregnancy has been reduced to less than 1%. As a result of these breakthroughs and as many of these individuals are of reproductive age, fertility issues are becoming increasingly important for this population. One population in which conception planning and reduction of horizontal HIV transmission warrants further research is HIV-discordant couples where the male partner is HIV-positive and the female partner is HIV-negative. Sperm washing is a technique carried out in a fertility clinic that separates HIV from the seminal fluid. Although sperm washing followed by intrauterine insemination significantly reduces the risk of horizontal HIV transmission, there has been limited access to the procedure in North America. Furthermore, little is known about the conception decision-making experiences of HIV-discordant couples who might benefit from sperm washing. Chart reviews and semi-structured interviews were completed with 12 HIV-discordant couples in Ontario, Canada. Couples were recruited through HIV clinics and one fertility clinic that offered sperm washing. Participants identified a number of factors that affected their decision-making around pregnancy planning. Access to sperm washing and other fertility services was an issue (cost, travel and few clinics). Participants identified a lack of information on the procedure (availability, safety). Sources of support (social networks, healthcare providers) were unevenly distributed, especially among those who did not disclose their HIV status to friends and family. Finally, the stigmatisation of HIV continues to have a negative affect on HIV-discordant couples and their intentions to conceive. Access to sperm washing and fertility service is significantly limited for this population and is accompanied with a number of challenges.
Article
Full-text available
The objective of this study was to describe attitudes, opinions, and perceived health needs of HIV-infected women in the United States. In this cross-sectional study, women were invited to participate in the Women Living Positive survey, a structured interview instrument with 45 questions. Collected data were deidentified and the margin of error was calculated as four percentage points. Incoming toll-free phone interviews were conducted from December 21, 2006, through March 14, 2007 among subjects recruited from a U.S. national network of AIDS counseling centers. Seven hundred HIV-infected women (43% African American, 28.5% Hispanic, 28.5% Caucasian; median age, 42.5 years) receiving combination antiretroviral therapy for 3 years or more replied to recruitment flyers. Overall, 55% of survey participants had never discussed gender-specific HIV treatment issues with their HIV care providers. Of the 45% who did discuss these issues, almost all (96%) were satisfied. On average, one-third of the women had seen three or more providers since beginning HIV treatment; 43% indicated they had switched providers because of communication issues. Among women who had been or were pregnant at the time of the survey (n=159), more than half (57%) had not had pre-pregnancy discussions with their HIV provider about the most appropriate HIV regimens for women attempting to become pregnant. Significant communication gaps exist between HIV-infected women and their providers when discussing gender-specific treatment issues. These data highlight a need for U.S. health care providers to incorporate discussion of gender-specific issues, including preconception and reproductive counseling, into management strategies for HIV-infected women.
Article
Full-text available
Antiretroviral chemoprophylaxis before exposure is a promising approach for the prevention of human immunodeficiency virus (HIV) acquisition. We randomly assigned 2499 HIV-seronegative men or transgender women who have sex with men to receive a combination of two oral antiretroviral drugs, emtricitabine and tenofovir disoproxil fumarate (FTC-TDF), or placebo once daily. All subjects received HIV testing, risk-reduction counseling, condoms, and management of sexually transmitted infections. The study subjects were followed for 3324 person-years (median, 1.2 years; maximum, 2.8 years). Of these subjects, 10 were found to have been infected with HIV at enrollment, and 100 became infected during follow-up (36 in the FTC-TDF group and 64 in the placebo group), indicating a 44% reduction in the incidence of HIV (95% confidence interval, 15 to 63; P=0.005). In the FTC-TDF group, the study drug was detected in 22 of 43 of seronegative subjects (51%) and in 3 of 34 HIV-infected subjects (9%) (P<0.001). Nausea was reported more frequently during the first 4 weeks in the FTC-TDF group than in the placebo group (P<0.001). The two groups had similar rates of serious adverse events (P=0.57). Oral FTC-TDF provided protection against the acquisition of HIV infection among the subjects. Detectable blood levels strongly correlated with the prophylactic effect. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT00458393.).
Article
Full-text available
To assess childbearing motivations, fertility desires and intentions, and their relationship with key factors, we conducted a cross-sectional survey among 181 HIV-infected women of reproductive age (15-44 years) receiving clinical care at two urban health clinics. Fertility desires (59%) and intentions (66% of those who desired a child) were high among this predominately African American sample of women, while the proportion with accurate knowledge of mother-to-child transmission (MTCT) was low (15%). Multivariate regression analyses identified factors significantly associated with the intention to have a child. Notably, age and parity did not remain significant in the adjusted model. The discrepancies between expressed desires and intentions for future childbearing, and the strong role of perceived partner desire for childbearing emphasize the need for universal reproductive counseling to help women living with HIV navigate their reproductive decisions and facilitate safe pregnancies and healthy children.
Article
Ninety years ago the isolation of insulin transformed the lives of people with type 1 diabetes. Now, models based on empirical data estimate that a 25-year-old person with HIV, when appropriately treated with antiretroviral therapy, can expect to enjoy a median survival of 35 years, remarkably similar to that for someone of the same age with type 1 diabetes. It is high time we normalised the lives of people living positively with HIV. This includes the basic human right to conceive and raise children. HIV-positive individuals may be in serodiscordant relationships or in seroconcordant relationships. As health care providers, it is our responsibility to ensure we understand the opportunities and risks of natural conception in these scenarios, so that we can help our patients to make informed decisions about their own lives. Most of all, it is our duty to make family planning in the setting of positive prevention as safe as we can. This includes informed decisions on contraception, adoption, fostering, conception and prevention of mother-to-child transmission. Some months ago a dedicated group of individuals, invited and sponsored by the Southern African HIV Clinicians Society, came together in Cape Town to devise guidance in this area, recognising that there are ideal strategies that may be outside the realm of the resource constraints of the public sector or health programmes in southern Africa. This guideline therefore attempts to provide a range of strategies for various resource settings. It is up to us, the providers, to familiarise ourselves with the merits/benefits and risks of each, and to then engage patients in meaningful discussions. All the above, however, is based on the premise and prerequisite that the subject of family planning is actively raised and frequently discussed in our patient encounters. Please find a link to the update of this guideline: http://sajhivmed.org.za/index.php/hivmed/article/view/399
Article
Although perinatal HIV infections are declining in the United States, there is no single source of nationally representative data available to estimate the number of infants born to HIV-infected women in the United States and its dependencies. This study determines the total number of births to HIV-positive women in the United States and 5 dependent areas in 2006. Diagnosed stage 1 or 2 HIV disease in the United States were based on reported data from 39 areas that conducted confidential name-based HIV case reporting and stage 3 HIV from all areas in the United States. A zero-inflated Poisson model was used to estimate the number of women aged 13-44 years living with diagnosed stage 1 or 2 HIV disease in the United States. The number of undiagnosed HIV-infected women (stage 1 or 2) of childbearing age was estimated from the number of reported Stage 3 HIV (ie, AIDS) cases using a back-calculation method. An estimated 115,200 women aged 13-44 years were living with stage 1 or 2 HIV disease in 2006. A total of 56,200 women were living with diagnosed stage 3 disease. The estimated number of births to all women living with HIV disease (diagnosed or undiagnosed) was 8700 [95% Confidence Interval (CI): 8400 to 8800] in 2006. The number of infants born to HIV-infected women in 2006 was approximately 30% greater than the number of such births (6075-6422) in 2000. This increase highlights the need to continue and strengthen efforts to prevent perinatal HIV transmission in the United States.
Article
The current study addresses fertility desires and considerations among 143 HIV serodiscordant, opposite-sex couples (in which only the male partner is HIV positive) in the Northeastern U.S. Couples responded to questionnaires during their initial consultation for assisted reproduction, and data were collected over 7 years and analyzed retrospectively. Results indicated that a majority of the male participants had HIV when they met their partner, and a majority also disclosed their HIV status upon meeting. Most couples reported that they had previously discussed or considered a host of fertility-related issues, including the potential risk of HIV infection to the mother and the fetus during the process of fertility treatment. The majority of couples had also discussed the possibility that the male partner could die prematurely due to HIV/AIDS and had considered making arrangements for third-party parenting in the event of the male partner's death. If their fertility treatment were to be successful in the future, most couples desired additional children, and most believed that their future child should be told of the male partner's HIV status. Predictors of the desire for additional children after successful fertility treatment included: younger age, shorter relationship duration, being childless currently, and beginning their relationship after the male partner had already been diagnosed as HIV positive. Future research on fertility desires should include perspectives of HIV positive men on fatherhood, as well as concerns and issues specific to HIV serodiscordant couples.