Client and provider knowledge and views on safer conception for people living with HIV (PLHIV)

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DOI: 10.1016/j.srhc.2016.03.005
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Abstract
Objective(s): The childbearing needs of people living with HIV (PLHIV) and the experiences of healthcare providers serving them are explored. We examine provider and client knowledge and views on safer conception methods. Methods: The study uses exploratory qualitative research to understand provider and client perspectives on childbearing and safer conception. Interviews were conducted at 3 sites (1 rural, 2 urban) in eThekwini District, KwaZulu-Natal, South Africa between May 2011 and August 2012, including in-depth interviews with 43 PLHIV, 2 focus group discussions and 12 in-depth interviews with providers. Results: Clients had little knowledge and providers had limited knowledge of safer conception methods. While clients were eager to receive counseling on safer conception, providers had some hesitations but were eager to receive training in delivering safer conception services. Clients and providers noted that biological parentage is a major concern of PLHIV. Clients were willing to use any of the described methods to have biological children but some expressed concerns about potential risks associated with timed unprotected intercourse. Male clients required access to reproductive health information. Conclusions: Providers need to routinely initiate discussions with clients about childbearing intentions. Providers need to be enabled with approved guidelines and training to support client access to safer conception methods.
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Client and provider knowledge and views on safer conception for
people living with HIV (PLHIV)
Deborah L. Mindry
a,
*, Cecilia Milford
b
, Letitia Greener
b
, Ross M. Greener
b
,
Pranitha Maharaj
c
, Thabo Letsoalo
c
, Chantal Munthree
c
, Tamaryn L. Crankshaw
d
,
Jennifer A. Smit
b,c
a
Center for Culture and Health, Semel Institute, University of California, Los Angeles, USA
b
MatCH Research (Maternal, Adolescent and Child Health), Dept. of Obstetrics and Gynecology, Faculty of Health Sciences, University of Witwatersrand,
Durban, South Africa
c
School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa
d
Health Economics HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
ARTICLE INFO
Article history:
Received 16 November 2015
Revised 22 March 2016
Accepted 28 March 2016
Keywords:
Safer conception
Childbearing
People living with HIV
Health care providers
South Africa
ABSTRACT
Objective(s): The childbearing needs of people living with HIV (PLHIV) and the experiences of health-
care providers serving them are explored. We examine provider and client knowledge and views on safer
conception methods.
Methods: The study uses exploratory qualitative research to understand provider and client perspec-
tives on childbearing and safer conception. Interviews were conducted at 3 sites (1 rural, 2 urban) in
eThekwini District, KwaZulu-Natal, South Africa between May 2011 and August 2012, including in-
depth interviews with 43 PLHIV, 2 focus group discussions and 12 in-depth interviews with providers.
Results: Clients had little knowledge and providers had limited knowledge of safer conception methods.
While clients were eager to receive counseling on safer conception, providers had some hesitations but
were eager to receive training in delivering safer conception services. Clients and providers noted that
biological parentage is a major concern of PLHIV. Clients were willing to use any of the described methods
to have biological children but some expressed concerns about potential risks associated with timed un-
protected intercourse. Male clients required access to reproductive health information.
Conclusions: Providers need to routinely initiate discussions with clients about childbearing intentions.
Providers need to be enabled with approved guidelines and training to support client access to safer con-
ception methods.
© 2016 Elsevier B.V. All rights reserved.
Introduction
Supporting the fertility desires and reproductive health needs
of people living with HIV (PLHIV) is an important reproductive health
right and key issue in the HIV prevention agenda
[1,2]. A growing
body of research has demonstrated that many PLHIV wish to (and
will have) biological children and has established the need for routine
safer conception (SC) services to reduce associated HIV transmis-
sion risks
[3–7]. In a context of high HIV prevalence, research in South
Africa has reported between 29% and 57% of PLHIV desire biolog-
ical children
[8–11]. The 2012 antenatal survey reported a national
HIV prevalence of 29.5% among pregnant women with a preva-
lence of 37.4% in KwaZulu-Natal
[12]. Despite this, there remains
limited understanding of provider perspectives of SC methods, as
well as what SC methods clients would be willing to utilize.
HIV prevention messaging continues to dominate the reproduc-
tive health service landscape for PLHIV, with an emphasis on condom
use to prevent HIV transmission and to avoid unintended concep-
tion
[13]. Support for PLHIV to have children without transmitting
HIV to their partners or future children is largely lacking [10,14,15].
Preventing mother to child transmission of HIV (PMTCT) has been
an important first step in addressing the risks of vertical transmis-
sion associated with childbearing
[16,17]. A critical next step is
addressing the risks of horizontal transmission among HIV
serodiscordant partners who are trying to conceive
[6].
In 2011 the South African HIV Clinician’s Society published clin-
ical guidelines recommending SC be part of routine HIV care
[18].
These guidelines, which have yet to be systematically implemented,
outline low cost SC methods (most likely to be implemented) which
include the use of ART (antiretroviral treatment) by the infected
partner, with timed unprotected intercourse for an HIV-positive male
* Corresponding author. UCLA Center for Culture and Health, Semel Institute, 760
Westwood Blvd., Westwood, CA 90024. Tel.: 1/626/423 4189.
E-mail address:
dmindry@ucla.edu (D.L. Mindry).
http://dx.doi.org/10.1016/j.srhc.2016.03.005
1877-5756/© 2016 Elsevier B.V. All rights reserved.
Sexual & Reproductive Healthcare ■■ (2016) ■■■■
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with a negative female partner or HIV concordant couples, and
manual self-insemination during ovulation for an HIV-positive female
with a negative male partner utilizing his collected sperm sample
[19]. Sperm washing with insemination or in vitro fertilization is
a high cost, no risk option for an HIV-positive male with a nega-
tive female partner
[20,21]. This paper explores health provider and
client knowledge and views on these SC methods.
Methods
This study was conducted at three antiretroviral treatment (ART)
clinics in eThekwini District, KwaZulu-Natal, South Africa, between
May 2011 and August 2012. Since this was exploratory research,
we selected clinics in different settings to ensure a range of expe-
riences, knowledge and views on SC among PLHIV and the healthcare
providers serving them. One clinic served a large rural communi-
ty, and the other two were urban clinics one served a lower income
population (urban clinic 2) and the other (urban clinic 1) a more
economically diverse population.
The clinic nurse in charge (at the rural site and urban clinic 3)
helped to identify men and women living with HIV, between the
ages of 18 and 55, who either had a child since their HIV diagno-
sis or who desired a child in the future. Twenty-two men and twenty-
one women agreed to participate in individual in-depth interviews.
We used convenience sampling to recruit 20 different providers (at
the rural site and urban clinic 2) to participate in two focus group
discussions and in individual interviews. Providers were informed
of the study at staff meetings and volunteers were asked to contact
study staff if they were interested in participating. Twelve inter-
views were conducted first (five nurses, five doctors, two counselors),
followed by two focus group discussions (13 participants). Doctors
were excluded from focus groups to ensure provider authority struc-
tures did not constrain nurses and counselors expressing their views
(
Table 1). The sample was selected using non-probability sam-
pling. Participants were selected based on availability, consent to
participate, experiences, and characteristics unique to the target
groups.
Client interviews were conducted in isiZulu or English, and
focused on childbearing desires, experiences, knowledge, and views
of PMTCT and SC care. All clients were asked about their knowl-
edge and views on three SC methods: timed unprotected intercourse
(both partners living with HIV, or one partner’s HIV status unknown),
manual self-insemination (females living with HIV but not the male
partner), and sperm washing with clinic assisted insemination (male
living with HIV but not the female partner). Clients were also asked
to consider their partners’ views on these three SC methods and their
willingness to engage in SC care.
Provider interviews and focus groups were conducted in English
and focused on their experiences serving the childbearing needs of
PLHIV, their knowledge and views on the three SC methods de-
scribed above, and their views on the acceptability of these methods.
All interviews and focus group discussions were transcribed and
translated (as needed).
Ethics approval was obtained through the research ethics com-
mittees of the University of the Witwatersrand, the University of
KwaZulu-Natal, and the University of California, Los Angeles. The
KwaZulu-Natal Department of Health and three clinic sites provid-
ed their written support of the study. Signed informed consent was
obtained from all participants in the study prior to conducting in-
terviews and focus groups.
Analysis
Interviews were coded using Atlas.ti (version 6.2, Berlin,
Germany). The coding scheme was developed using a grounded ap-
proach
[22]. Themes developed for the semi-structured interviews
shaped the dominant themes that emerged in the coding process.
New themes and subthemes emerged in this grounded approach
to coding. The coding was conducted by the lead author and re-
viewed by a second qualitative researcher. Changes were made to
the coding scheme based on consensus agreement between the two
researchers.
Results
All forty-three client participants were Black African aged 22 to
55 years. All reported a desire to have a child in the future, while
nine reported currently trying to conceive (one was pregnant)
(
Table 2).
Client knowledge of safer conception
Few clients had any knowledge of methods to avoid horizontal
transmission of HIV when trying to conceive. Most had not spoken
with providers about their childbearing desires and only cited
condom use to ensure safer/protected sex.
“[I]f you do not want to conceive a baby, you can use the pro-
tection, now if you want to make a baby, no I do not understand
[know]” (female, 45, urban).
Table 1
Participants at three study sites.
Site 1: Rural clinic Site 2: Urban clinic 1 Site 3: Urban clinic 2 Total
HIV + client interviews 11 females 10 females 21 females
10 males 12 males 22 males
HCP Focus Groups 3 nurses 4 nurses 7 nurses
4 counselors 2 counselors 6 counselors
HCP Interviews 2 nurses 3 nurses 5 nurses
3 doctors 2 doctors 5 doctors
1 counselor 1 counselor 2 counselors
Table 2
Client demographics.
Urban Rural Total
Male Female Male Female
ART (Yes/No) 9/3 10/0 10/0 10/1 39/4
Relationship status
(Discordant/Concordant/
Don’t Know)
1/9/0 2/5/2 2/5/2 2/7/1 7/26/5
Status disclosed (Yes/No) 8/0
b
7/2 7/2 9/1 31/5
No. children (0/1–2/ > 3) 3/5/4 1/7/2 3/5/2 3/8/1 10/25/9
Child post HIV (Yes/No) 2/10 2/8 1/8 6/5 11/31
Desire child (Yes/No) 12/0 10/0 10/0 10/1 42/1
Currently trying (Yes/No) 1/7
b
3/7 2/8 3
a
/8 9/30
a
One woman had just been notified that she was pregnant.
b
Missing data or not in a relationship, so some not relevant.
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One man, who had discussed his desire to have more children
with providers, still reported no knowledge of SC methods,
“I have never heard advice of these things or anything from the
medical people” (43, urban).
The lack of adequate counseling of men on reproductive matters
was a consistent theme. It was stated that women primarily re-
ceived reproductive counseling.
“No, I have not received [information on SC] […] perhaps the
person who has that information is the mother of the child who
usually goes and talks about something of that sort.” (male, 38,
urban)
Clients who had heard of SC most often heard about it via the
media.
“I have heard about when they take the sperm and put it in you,
in that way your partner is safe. […] He has to know your status.
Then you will go to the doctors together and the doctor will help
you and he will examine both of you. Then he will take out the
man’s sperm and would help with depositing it in you, in that
way you will conceive. […] I don’t have information [how it is
deposited]. […] I usually hear when people talk on the radio about
it and also on television.” (female, 34, urban)
Horizontal transmission and sero-sorting
Twenty six clients reported having a sero-concordant partner.
Sero-sorting (entails finding an HIV-positive partner) emerged as
a common method to avoid the risk of horizontal transmission since
their partner was already living with HIV.
“[T]he only information I have is that since I am HIV-positive, I
am supposed not to have sex with someone who is not HIV-
positive. […] It is much better to live with this same person who
has HIV rather than going out and take someone who is not
HIV-positive.” (male, 43, urban)
Provider knowledge of safer conception
We interviewed two counselors, five nurses, and five doctors aged
29 to 59 years, ten of whom were women. In addition, six coun-
selors and seven nurses participated in focus groups (
Table 1).
Providers reported not routinely discussing childbearing inten-
tions with clients living with HIV and expressed frustration with
clients who came to them already pregnant.
“….I think because we are getting people who just fall preg-
nant, mostly we find out when we are talking that they are
already pregnant, […] it’s rare where you will find that someone
who is pregnant has ever discussed that issue with a counselor
or a doctor.” (female, counselor, urban)
“We ask them about their sexual health, about contraception,
about children, if their children have been tested. It does come
up in the conversation but it’s not for each patient that we would
ask, ‘Are you planning another child?’.” (focus group, nurse, urban)
A few providers expressed some knowledge of SC methods for
PLHIV, however most had limited or partial and/or inaccurate knowl-
edge and at least half in each category of providers did not have
any SC knowledge.
“I am not sure what they really do but what I have heard is that
they use a syringe to inject into the vagina and the partner won’t
have to have sexual contact with the infected partner because
the sperm actually is not positive or negative. But I don’t know
how safe it is. I don’t have good knowledge about it; I have never
seen it done.” (female, nurse, urban)
Among providers who had some knowledge of SC only, one
(a counselor) described advising clients on the use of timed inter-
course. Most did not know about self-insemination or sperm
washing. Once described, most viewed sperm washing as an un-
likely option due to resource limitations and costs, and thus
considered timed unprotected intercourse in conjunction with ART
and viral suppression as the more viable option.
“The main thing is that their viral load is suppressed and that
they take their tablets; that they are careful about their sexual
health. And if they are female and they wish to have babies, they
should know the woman’s cycle and know when it is best to have
a baby.” (male, doctor, rural)
Most providers reported having limited knowledge regarding
women’s reproductive cycles and felt uncertain about adequately
counseling clients on timed intercourse. Counselors and nurses pre-
ferred to refer clients to doctors for SC counseling.
“Mainly when the husband and wife come and say we want a
child we would refer them to the doctor. I wish I could do more,
and know how we can help them if they want to [have children].”
(female, nurse, urban).
All providers expressed a need for additional training on SC
methods and reproductive healthcare for PLHIV as well as stan-
dardized SC guidelines.
“[C]lear guidelines would be helpful, documented, that every-
one is agreed on. And especially for counselors, to make sure their
training is adequate when they are doing the pre-ARV training.
Because the majority of information that the patients receive
comes from the counselors, so we need to make sure that their
training is adequate.” (male, doctor, rural)
Client knowledge and views on specific safer conception methods
All clients were asked their knowledge and views on each of the
three methods described above.
Timed self-insemination
Clients had not heard about timed self-insemination (recom-
mended for couple with HIV-positive female and HIV-negative male)
and most had difficulty understanding the method, often confus-
ing it with clinic-assisted in vitro fertilization. Once described, clients
were generally receptive to using this method. One woman thought
her partner would agree to use this method because,
“[t]here would be no misunderstanding that they were using
someone else’s sperm. He would actually do it himself and see
his own sperm and know this is my child.” (34, rural)
Similarly a male client expressed support for self-insemination:
“I think this is the right method because she does not get in-
fected, neither does the child. […]So in a desperate situation of
really wanting a child, I would use it” (35, rural).
Another client, who did not know her partner’s status and had
not disclosed her HIV-positive status, felt self-insemination could
be helpful in avoiding blame for transmitting HIV to her partner.
“If I use this strategy my partner will not blame me that I in-
fected him, he will not complain, he will know that when we
have sex we will use condoms, for a child we will use this
strategy.” (34, urban)
Clients were optimistic about timed self-insemination and saw
this method as useful in attaining their childbearing goals.
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Sperm washing and clinic assisted insemination
Concerns about biological parentage were expressed by both men
and women when sperm washing with clinic assisted insemina-
tion was discussed (for couples where an HIV-positive male has an
HIV-negative female partner). Men were concerned about ensur-
ing that their own sperm was being used.
“No, to me it is not right because […] I would know that child
is not mine.” (male, 38, urban)
Once assured that his own sperm would be used he said that
was “the very right one. […] It is alright if they are going to take
mine and insert it in her.”
Female clients noted that this was a good method for women
who were not living with HIV but had a male partner living with
HIV. Some said that if a man really wanted a child, he would agree
to this method.
“He has to agree to it because it is preventing him infecting [his
partner]. If he doesn’t agree then he will infect [her].” (female,
32, rural)
Both male and female clients expressed concerns about the costs
and complexity of the process.
Timed unprotected intercourse
When discussing the use of timed unprotected intercourse, for
couples where partner status is unknown or where one or both part-
ners are HIV-infected, clients expressed less confidence as they felt
that unprotected intercourse during ovulation still posed a risk of
infection.
“I cannot trust that [method].” (male, 38, rural)
“I think it is very risky. [….] It’s better if you know that you are
protected and not have unprotected sex. I am scared.” (female,
31, urban)
A few clients stated they would consider using this method
despite potential risks.
“Having this in mind now, I am really starting to see that there
are other ways [to conceive]. So it can be risky […] but it cannot
be risky to a person that is serious to have a child. So, the method
is very helpful…” (male, 23, urban)
Many clients found this method appealing since it was more
“natural” and did not require clinic visits.
“This is a good method. We both have sex the natural way.” (male,
28, rural)
Some females told us their partners would support this method
because,
“[H]e would be very happy that he won’t use the condom. […]
He would have day off from using condoms.” (female, 28, rural)
Most clients indicated they would need comprehensive coun-
seling on timed unprotected intercourse as few had knowledge of
ovulation and would need assistance determining the ovulation
period. The only client with any knowledge of this had received some
counseling from providers.
“They told me that if you when you get [your] period because
we are on HIV [treatment], they say we must use a condom, only
when I get my period, so I count from that day when I finish
my period, so on the seventh [day], you must have sex only on
that day… So then if we have it on [that day] then we must
carry on with a condom. […] So in future we are using condoms
every day.” (female, 36, urban)
Clients expressed a strong desire for support from providers to
ensure that they safely conceive and that the risk to the child was
addressed. Reducing risk to their partner was something clients did
not expect and this was information they were eager to obtain.
“Sex is just for making love; so if you do want to have children,
I would do any of these [SC] options because I want to have
children.” (male, 45, rural)
Provider concerns over discussing safer conception methods
with clients
Providers expressed discomfort advising clients about SC
methods.
“I think the other fear about us as nurses, we think that if we
talk about preconception, it’s like we’re encouraging them to have
more and more children.” (focus group, nurse, urban)
While another provider noted that providing “relevant informa-
tion” to couples about childbearing was important she cautioned
that,
“… at the same time making sure that we are not encouraging
pregnancy to those who are HIV-positive because even though
the treatment does work, sometimes it does fail to do what it
is supposed to do. Children need to be raised up, so we might
end up having lots of orphans. On the other hand, I would say
let us encourage it and give more information on it…” (female,
counselor, urban).
A few cautioned that not all providers are comfortable discuss-
ing sexual matters with clients.
“[N]ot everyone is comfortable talking about sexuality; one would
assume that everyone in an ARV [antiretroviral] clinic is happy
to talk about sex but maybe not everyone is.” (male, doctor, rural)
Regarding specific SC methods, providers noted that they were
not always comfortable discussing methods, in part, because they
lacked adequate information.
“[W]ell to be honest, I’m not even comfortable to talk about
[using] a syringe [for insemination]. Because it is something I’m
really, really not too sure [about].” (focus group, nurse, urban)
Providers also discussed issues related to social acceptability. In
the rural clinic, providers believed clients may be concerned about
ensuring paternity.
“We are located in a rural area and our people here are illiter-
ate so it depends on their level of understanding. Let me make
an example, if a 40 year old wants an artificial insemination
maybe he is married, firstly, it depends on our cultural beliefs
plus they would not know the surname of the sperm [patriar-
chal affiliation of child].” (focus group, counselor, rural)
Some providers thought timed intercourse would be more
acceptable:
“Obviously there are other options, like donations of sperm, and
I think for most people they don’t want that option. They just
want to know which the safest period is, my viral load is sup-
pressed, as long as the partner knows the risk, it’s basically zilch,
but there’s the risk. So they can be helped.” (male, doctor, rural)
When discussing implementation of SC counseling in clinics, pro-
viders expressed concerns about ensuring men’s compliance with
recommended procedures. They feared cessation of condom use
during timed intercourse would undermine efforts to ensure condom
usage as an HIV prevention strategy.
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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-
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4 D.L. Mindry et al./Sexual & Reproductive Healthcare ■■ (2016) ■■■■
“He obviously won’t want to use condoms; he’s going to ask ‘why
do I need to use condoms?’” (focus group, nurse, urban)
Discussion
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
many settings
[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
[27,28].
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
[23,24].
Conclusions
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
[7]. Providers also need
values clarification training to help them separate their personal
beliefs and clients’ rights to have children
[30]. 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
[6]. 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.
Acknowledgments
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
6 D.L. Mindry et al./Sexual & Reproductive Healthcare ■■ (2016) ■■■■
  • Article
    Full-text available
    Abstract Background Safer conception services promote the reproductive health and rights of families, while minimizing HIV transmission risks between partners trying to conceive, as well vertical transmission risks. Implementation data, including clients’ experiences utilizing safer conception services in sub-Saharan Africa are limited. Methods Hillbrow Community Health Centre began offering safer conception services for individuals and couples affected by HIV in Johannesburg, South Africa in June 2015. A stratified sub-sample of safer conception clients were consecutively recruited from April 2016–August 2017 for a cross-sectional interview assessing clients’ perceptions of service acceptability and value, as well as perceived safer conception knowledge and self-efficacy. Visual analog scales from 0 to 100 were used to measure clients’ experiences; scores were classified as low, moderate and high acceptance/value/knowledge/self-efficacy if they were
  • Article
    Pre-exposure prophylaxis (PrEP) is a well-established biomedical HIV prevention strategy and recommended to reduce HIV risk during peri-conception, pregnancy and breastfeeding. Efforts are needed to translate global recommendations into national guidelines and implementation strategies. This article presents the current status of policy guidance for the use of PrEP during peri-conception, pregnancy and breastfeeding, with a particular focus on high prevalence countries, including those in sub-Saharan Africa. PrEP clinical guidelines released by ministries of health or other national-level health bodies, with a particular focus on recommendations for PrEP use during peri-conception, pregnancy and breastfeeding, were reviewed and summarised. Among countries with PrEP guidelines and/or policy, pregnancy is recognised as a period with increased HIV vulnerability, and some recommend PrEP use specifically during pregnancy. Only one country notes that PrEP is contraindicated during pregnancy, recognising a gap in complete safety data from women using PrEP throughout pregnancy. PrEP is not contraindicated as a peri-conception HIV prevention strategy in any country, but only three countries have specific guidance for peri-conception HIV prevention. Multiple barriers to the implementation of PrEP during pregnancy and breastfeeding are discussed, including barriers at the policy, health systems, social and personal levels. Although pregnancy is a period of heightened risk and fertility rates are high in many settings with high HIV burden, few PrEP policies have included guidance for PrEP use specific to peri-conception, pregnancy and breastfeeding periods. This gap can be overcome by the development or adoption of national clinical guidelines and implementation strategies from exemplary countries.
  • Article
    Full-text available
    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.
  • Article
    Full-text available
    Background: Preconception antiretroviral therapy (PCART) followed by sustained viral suppression is effective in preventing mother-to-child transmission of HIV. The rates of persistent and transient viraemia in such patients have not been prospectively assessed in South Africa. Objectives: We determined the prevalence of transient and persistent viraemia in HIV-positive women entering antenatal care on PCART and studied variables associated with viraemia. Methods: We performed a prospective cross-sectional observational study of HIV-positive pregnant women presenting to a primary healthcare facility in KwaZulu-Natal. All had received at least 6 months of first-line PCART. Viral load (VL) was measured, patients were interviewed, adherence estimated using a visual analogue scale and adherence counselling provided. Viral load was repeated after 4 weeks where baseline VL exceeded 50 copies/mL. Results: We enrolled 82 participants. Of them, 59 (72%) pregnancies were unplanned. Fifteen participants (18.3%) were viraemic at presentation with VL > 50 copies/mL. Of these, seven (8.5%) had viral suppression (VL < 50 copies/mL), and eight remained viraemic at the second visit. Adherence correlated significantly with viraemia at baseline. Level of knowledge correlated with adherence but not with lack of viral suppression at baseline. Socio-economic indicators did not correlate with viraemia. No instances of vertical transmission were observed at birth. Conclusions: Approximately 20% of women receiving PCART may demonstrate viraemia. Half of these may be transient. Poor adherence is associated with viraemia, and efforts to encourage and monitor adherence are essential. The rate of unplanned pregnancies is high, and antiretroviral therapy programmes should focus on family planning needs of women in the reproductive age group to prevent viral non-suppression prior to pregnancy.
  • Article
    Context: Safer-conception counseling may help people living with HIV to reduce the risk of transmission to partners and children. However, such counseling is rarely offered or evaluated in low-income countries. Methods: In 2014-2015, in-depth qualitative interviews were conducted at a Ugandan HIV clinic with 42 HIV-positive clients and 16 uninfected partners who had participated in a safer-conception counseling intervention for serodiscordant couples seeking to have a child. Participants attended up to six monthly counseling sessions in which they received instruction and ongoing support in using the safer-conception method they selected. Content analysis of interview transcripts was used to identify themes related to the benefits and challenges of safer-conception counseling. Results: Almost two-thirds of participants felt that safer-conception counseling was an empowering experience that enabled them to make informed choices regarding childbearing, learn how to conceive safely and understand how to stay healthy while trying to conceive. Timed unprotected intercourse was the most frequently used safer-conception method. Seven couples had successful pregnancies, and no uninfected partners seroconverted. Participants' primary concerns and challenges regarding counseling and method use were issues with manual self-insemination, difficulty with engaging partners and fear of HIV infection. Conclusions: Counseling can help HIV-infected individuals make informed choices about childbearing and safer-conception methods; however, a controlled clinical trial is needed to determine whether clients use such methods correctly and to assess rates of pregnancy and transmission. Policymakers need to consider including safer-conception counseling as part of routine HIV care.
  • Article
    Full-text available
    We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception interventions. Following PRISMA guidelines, we searched fifteen electronic databases using the following inclusion criteria: SCS research in HIV-affected couples; published after 2007; in sub-Saharan Africa; primary research; peer-reviewed; and addressed a primary topic of interest (SCS availability, feasibility, and acceptability, and/or education and promotion). Researchers independently reviewed each study for eligibility using a standardized tool. We categorize studies by their topic area. We identified 41 studies (26 qualitative and 15 quantitative) that met inclusion criteria. Reviewed SCSs included: antiretroviral therapy (ART), pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC). SCS were largely unavailable outside of research settings, except for general availability (i.e., not specifically for safer conception) of ART and VMMC. SCS acceptability was impacted by low client and provider knowledge about safer conception services, stigma around HIV-affected couples wanting children, and difficulty with HIV disclosure in HIV-affected couples. Couples expressed desire to learn more about SCS; however, provider training, patient education, SCS promotions, and integration of reproductive health and HIV services remain limited. Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge. SCS are not yet widely available to HIV-affected African couples. Successful implementation of SCS requires that providers receive training on effective SCS and provide couple-based safer conception counseling to improve disclosure and communication around fertility intentions and reproductive health.
  • Article
    Full-text available
    High rates of fertility desires, childbearing and serodiscordant partnerships among people living with HIV (PLHIV) in Uganda underscore the need to promote use of safer conception methods (SCM). Effective SCM exist but few PLHIV benefit from provider-led safer conception counseling (SCC) and comprehensive national SCC guidelines are still lacking. Providers’ self-efficacy, intentions and attitudes for SCC impact provision and should inform development of services, but there are no longitudinal studies that assess these important constructs. This study reports on changes in providers’ knowledge, attitudes, motivation and confidence to provide SCC among a 24-month observational cohort of Ugandan HIV providers. Compared to baseline, providers evidenced increased awareness of SCM, perceived greater value in providing SCC, saw all SCM but sperm washing as likely to be acceptable to clients, reported consistently high interest in and peer support for providing SCC, and perceived fewer barriers at the 24-month follow-up. Providers’ intentions for providing SCC stayed consistently high for all SCM except manual self-insemination which decreased at 24 months. Self-efficacy for providing SCC increased from baseline with the greatest improvement in providers’ confidence in advising serodiscordant couples where the man is HIV-infected. Providers consistently cite the lack of established guidelines, training, and their own reluctance to broach the issue with clients as significant barriers to providing SCC. Despite providers being more interested and open to providing SCC than ever, integration of SCC into standard HIV services has not happened. Concerted efforts are needed to address remaining barriers by establishing national SCC guidelines and implementing quality provider training.
  • 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
    The reproductive desires of people living with HIV/AIDS (PLHIV) of low socioeconomic standing attending public health facilities in South Africa were studied. HIV-positive men, pregnant and non-pregnant women were recruited from two clinics at a large public hospital in Tshwane, South Africa. Individual interviews were used to explore the reproductive desires of HIV-positive participants. HIV counsellors' perceptions of their clients' reproductive desires were explored during focus group discussions. Parenthood proved to be an important factor to all participants in continuation of the family and establishing their gender identities, despite the possible risk of HIV transmission and community stigmatization. Different cultural procreation rules for men and women and stigmatizing attitudes towards PLHIV affected their reproductive decision making. Women had the dilemma of choosing which community expectations they wanted to fulfil. Community stigmatization towards PLHIV was visible in the negative attitudes of some HIV counsellors regarding HIV and procreation. Because the reproductive desires of PLHIV are currently not given high priority in HIV prevention and family planning in the public health sector in South Africa, the prevention of HIV transmission may be jeopardized. These results necessitate the integration of HIV and sexual and reproductive health counselling on a primary health care level. Copyright © 2015 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
  • Article
    Intended conception likely contributes to a significant proportion of new HIV infections in South Africa. Safer conception strategies require healthcare provider-client communication about fertility intentions, periconception risks, and options to modify those risks. We conducted in-depth interviews with 35 HIV-infected men and women accessing care in South Africa to explore barriers and promoters to patient-provider communication around fertility desires and intentions. Few participants had discussed personal fertility goals with providers. Discussions about pregnancy focused on maternal and child health, not sexual HIV transmission; no participants had received tailored safer conception advice. Although participants welcomed safer conception counseling, barriers to client-initiated discussions included narrowly focused prevention messages and perceptions that periconception transmission risk is not modifiable. Supporting providers to assess clients' fertility intentions and offer appropriate advice, and public health campaigns that address sexual HIV transmission in the context of conception may improve awareness of and access to safer conception strategies.
  • Article
    The risk of human immunodeficiency virus (HIV) transmission to the female partner, or potential offspring of an HIV-1 infected man can be reduced using semen decontamination procedures before assisted reproductive treatment (ART). The objective of this study was to determine the efficiency of decontaminating semen samples (n = 186) from 95 HIV-1 sero-positive patients. Aliquots of neat semen were submitted for viral validation by qualitative and quantitative polymerase chain reaction. Semen samples were processed by density gradient centrifugation in combination with a ProInsert™ tube after which aliquots of the processed sperm samples were analysed for the presence of HIV-1. Fifty-four percent of all tested neat semen samples tested positive for HIV-1 DNA, RNA or both (13.4%, 11.3% and 29.0%, respectively). From a total of 103 processed sperm samples that were submitted for viral validation, two samples tested positive for HIV-1 DNA and none for RNA. In conclusion, semen processing with the ProInsert™ followed by viral validation of processed sperm samples should be carried out when providing ART to couples where the male partner is HIV-1 sero-positive. Copyright © 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
  • Article
    A growing understanding in the international public health community of the role of gender in reproductive health has helped to make reproductive health professionals aware of the need to develop creative strategies to reach men. While pilot programs and initiatives for including men in family planning and other reproductive health services have existed for more than 20 years in a number of countries only few are well-established and even fewer have been fully integrated into countries health care systems. Program managers and policymakers in many countries have routinely assumed that men are not interested in or supportive of family planning and contraceptive use even though recent research indicates that many men are. Research also indicates that many women want men to become more involved in reproductive health decision-making and activities. 145 men and women from more than a dozen mainly African and Asian countries met in Mombasa Kenya in May 1997 to share their experiences with knowledge of and concerns about fostering mens involvement in reproductive health care. Conference participants developed and presented plans to create programs for men in their countries with the goal of integrating them into existing national reproductive health systems.
  • Article
    Safer conception strategies create opportunities for HIV-serodiscordant couples to realize fertility goals and minimize periconception HIV transmission. Patient-provider communication about fertility goals is the first step in safer conception counseling. We explored provider practices of assessing fertility intentions among HIV-infected men and women, attitudes toward people living with HIV (PLWH) having children, and knowledge and provision of safer conception advice. We conducted in-depth interviews (9 counselors, 15 nurses, 5 doctors) and focus group discussions (6 counselors, 7 professional nurses) in eThekwini District, South Africa. Data were translated, transcribed, and analyzed using content analysis with NVivo10 software. Among 42 participants, median age was 41 (range, 28-60) years, 93% (39) were women, and median years worked in the clinic was 7 (range, 1-27). Some providers assessed women's, not men's, plans for having children at antiretroviral therapy initiation, to avoid fetal exposure to efavirenz. When conducted, reproductive counseling included CD4 cell count and HIV viral load assessment, advising mutual HIV status disclosure, and referral to another provider. Barriers to safer conception counseling included provider assumptions of HIV seroconcordance, low knowledge of safer conception strategies, personal feelings toward PLWH having children, and challenges to tailoring safer sex messages. Providers need information about HIV serodiscordance and safer conception strategies to move beyond discussing only perinatal transmission and maternal health for PLWH who choose to conceive. Safer conception counseling may be more feasible if the message is distilled to delaying conception attempts until the infected partner is on antiretroviral therapy. Designated and motivated nurse providers may be required to provide comprehensive safer conception counseling.
  • Article
    Full-text available
    Men and women living with HIV with access to ARVs are living longer, healthier lives that can and often do include bearing children. Children occupy a key space in men and women's personal and social lives and often play a fundamental role in maintaining these relationships, irrespective of illness concerns. Couples living with HIV need to balance prevention needs and ill-health while trying to maintain healthy relationships. Health-care providers serving the reproductive needs of HIV-affected couples need to consider the social and relational factors shaping reproductive decisions associated with periconception risk behaviors. This paper based on qualitative research at three hospital sites in eThekwini District, South Africa, investigates the childbearing intentions and needs of people living with HIV (PLHIV), and the attitudes and experiences of health-care providers serving the reproductive needs of PLHIV, and client and provider views and knowledge of safer conception. This research revealed that personal, social, and relationship dynamics shape the reproductive decisions of PLHIV, and "unplanned" pregnancies are not always unintended. Additionally, conception desires are not driven by the number of living children; rather clients are motivated by whether or not they have had any children with their current partner/spouse. Providers should consider the relationship status of clients in discussions about childbearing desires and intentions. Although many providers recognize the complex social realities shaping their clients' reproductive decisions, they have outdated information on serving their reproductive needs. Appropriate training to enable providers to better understand the relationship and social realities surrounding their clients' childbearing intentions is required and should be used as a platform for couples to work together with providers toward safer conception. The adoption of a more participatory approach should be employed to equalize client-provider power dynamics and to ensure clients are more involved in decision-making about reproduction and conception.
  • Article
    Full-text available
    Abstract In this qualitative study, researchers assessed knowledge, acceptability and feasibility of safer conception methods [SCM; timed unprotected intercourse (TUI), manual self-insemination, and sperm washing] among various healthcare providers (n = 33) and 48 HIV clients with recent or current childbearing intentions in Uganda. While several clients and providers had heard of SCM, (especially TUI); few fully understood how to use the methods. All provider types expressed a desire to incorporate SCM into their practice; however, this will require training and counseling protocols, sensitization to overcome cultural norms that pose obstacles to these methods, and partner engagement (particularly men) in safer conception counseling.
  • Article
    Full-text available
    Introduction Introduction Safer conception interventions should ideally involve both members of an HIV-affected couple. With serodiscordant couples, healthcare providers will need to manage periconception risk behaviour as well tailor safer conception strategies according to available resources and the HIV status of each partner. Prior to widespread implementation of safer conception services, it is crucial to better understand provider perspectives regarding provision of care since they will be pivotal to the successful delivery of safer conception. This paper reports on findings from a qualitative study exploring the viewpoints and experiences of doctors, nurses, and lay counsellors on safer conception care in a rural and in an urban setting in Durban, South Africa. Methods We conducted six semistructured individual interviews per site (a total of 12 interviews) as well as a focus group discussion at each clinic site (a total of 13 additional participants). All interviews were coded in Atlas.ti using a grounded theory approach to develop codes and to identify core themes and subthemes in the data. Results Managing the clinical and relationship complexities related to serodiscordant couples wishing to conceive was flagged as a concern by all categories of health providers. Providers added that, in the HIV clinical setting, they often found it difficult to balance their professional priorities, to maintain the health of their clients, and to ensure that partners were not exposed to unnecessary risk, while still supporting their clients’ desires to have a child. Many providers expressed concern over issues related to disclosure of HIV status between partners, particularly when managing couples where one partner was not aware of the other's status and expressed the desire for a child. Provider experiences were that female clients most often sought out care, and it was difficult to reach the male partner to include him in the consultation. Conclusions Providers require support in dealing with HIV disclosure issues and in becoming more confident in dealing with couples and serodiscordance. Prior to implementing safer conception programmes, focused training is needed for healthcare professionals to address some of the ethical and relationship issues that are critical in the context of safer conception care.