“He obviously won’t want to use condoms; he’s going to ask ‘why
do I need to use condoms?’” (focus group, nurse, urban)
Routine provision of preconception services and safer concep-
tion counseling to PLHIV and their partners is required. Our research
indicates that PLHIV and providers in our study had very limited
knowledge of SC methods. Few clients had knowledge of SC methods
to prevent horizontal HIV transmission, relying on preventing trans-
mission through the use of condoms, which also prevents conception.
Research has previously highlighted the emphasis placed on condom
use by providers and in HIV education campaigns which preclude
open discussion of safer conception
[23,24]. This messaging is neither
helpful nor ethical to clients living with HIV who desire and intend
to become pregnant. When it came to fulﬁlling their desires to have
children, clients were not aware of ways to do so safely. Those who
knew anything about SC heard about it via media, but knew very
little about how this would actually work for them. Only one client
reported receiving counseling on timed unprotected intercourse.
Reproductive healthcare for men has historically been poor in
[25,26]; male participants lacked access to repro-
ductive knowledge and were usually dependent on female partners
for information. Ensuring men’s access to reproductive healthcare
is vitally important, not only for men’s health, but also to ensure
the health of their sexual partners. Reproductive healthcare should
be seen as a right for both men and women
When discussing the SC methods available, providers and clients
noted that men may be concerned about biological parentage and
would have anxieties about whether their own semen specimen
would be used to inseminate their partner. A number of clients ex-
pressed concerns about the risk of HIV transmission associated with
timed unprotected intercourse. Those who understood that limit-
ing unprotected intercourse to the period of ovulation would
minimize risks were willing to use this method describing it as more
“natural”. Clients were supportive of self-insemination in cases where
the female partner was living with HIV but the male partner was
not. Female clients felt that they or their male partner could be
assured that the semen sample was their own. Men living with HIV
were not averse to using clinic based services for sperm washing
should such services be available. Clients were motivated to ensure
not only that they had biological children but that they avoided trans-
mitting the virus to the child. They also wanted to ensure that they
and/or their partner remained healthy in order to raise their child.
Although client interviews reﬂected a strong need for SC coun-
seling, provider interviews revealed their hesitancy toward providing
such services given their limited knowledge, a lack of Department
of Health guidelines and training, concerns about client treatment
adherence, and providers’ personal beliefs
[23,29,30]. Providers ex-
pressed concerns about preconception counseling and encouraging
PLHIV to have children while a few noted that some providers are
uncomfortable discussing sexual matters with clients. They were
also concerned about clients’ ability to adequately implement the
SC methods and about male compliance with their recommenda-
tions. Providers desired training in reproductive health for PLHIV
as well as SC methods. Counselors and nurses were primarily re-
ferring clients who expressed childbearing desires to doctors, while
doctors stated that counselors are at the frontline in addressing such
issues with clients and also needed training
Clients have a strong desire to receive safer conception coun-
seling from providers and though providers express some concerns
about encouraging clients to have children, all had a strong desire
for clear guidelines. Providers had limited knowledge of reproductive
health and safer conception methods, and require training to ef-
fectively deliver these services. These ﬁndings are comparable to
those of Finocchario-Kessler et al. in Uganda
. Providers also need
values clariﬁcation training to help them separate their personal
beliefs and clients’ rights to have children
. South Africa’s clin-
ical guidelines for delivery of safer conception services need to be
reviewed and adapted for use within the National Department of
Health. Van Zyl and Visser suggest such care be integrated at the
primary care level
. Affordability issues, particularly with regard
to sperm washing, need to be addressed to ensure men living with
HIV who are in discordant relationships do not transmit the virus
to their partners. Providers need to routinely initiate discussions
with HIV-affected couples about their childbearing intentions. Since
clients report seeking sero-concordant partners it is important that
safer conception services include sero-concordant and not only sero-
discordant couples to ensure optimal outcomes and engagement
in PMTCT. Sero-concordant partners need information on safer con-
ception to minimize the risks of superinfection or transmission of
drug resistant strains of HIV, and to ensure engagement in PMTCT
services to reduce vertical transmission to the child. Nurses and coun-
selors are often the ﬁrst line of contact and should be placed at the
forefront of training in safer conception to provide clients with ap-
propriate information and assistance. Clients who are motivated to
have children are willing to use safer conception methods if they
can be assured the child will be their biological progeny.
This research was funded by an NIMH Fogarty International
Center and the University of California Global Health Institute’s
Women’s Health and Empowerment Center of Expertise (Award
Number R24TW008807); UCLA AIDS Institute, and the UCLA Center
for AIDS Research (AI28697). The views expressed here are solely
those of the authors. The author(s) declared no potential conﬂicts
of interest with respect to the research, authorship, and/or publi-
cation of this article.
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ARTICLE IN PRESS
Please cite this article in press as: Deborah L. Mindry, et al., Client and provider knowledge and views on safer conception for people living with HIV (PLHIV), Sexual & Repro-
ductive Healthcare (2016), doi: 10.1016/j.srhc.2016.03.005
5D.L. Mindry et al./Sexual & Reproductive Healthcare ■■ (2016) ■■–■■