Current HIV prevention strategies (condoms and abstinence) force HIV-serodiscordant couples to choose between risking HIV transmission to a partner, or accepting childlessness [
Cross-sectional studies indicate that people living with HIV are receptive to safer conception advice from providers [
Data demonstrating that ARVs minimize HIV transmission suggest that periconception risk-reduction interventions will require HCW involvement [
We present qualitative data resulting from interviews with 30 HIV-infected women and 20 HIV-infected men with serodiscordant sexual partners in Durban, South Africa. We previously reported on periconception risk behavior within this sample [
Participants were recruited from the antiretroviral (ARV) and preventing maternal-to-child-transmission (PMTCT) clinics within a state-aided (public/private partnership) general hospital serving a predominantly urban population from the greater Durban area where district antenatal clinic HIV prevalence is estimated at 41.5% [
Male participants were recruited from the ARV clinic and female participants were recruited from the ARV and PMTCT clinics. Inclusion criteria were (1) age 18–45 years; (2) HIV-positive; (3) pregnancy in the prior 12 months, including currently pregnant (for women); (4) partner of unknown or seronegative HIV status (prior to referent pregnancy) by participant report (father of the referent pregnancy for women, current sexual partner for men); (5) fluent in English or isiZulu; (6) able to give informed consent. Initial attempts to recruit men with partner pregnancy in the past year were unsuccessful, men were subsequently recruited independent of recent partner pregnancy. It is not clear if initial recruitment challenges were due to sensitivities of reporting partner pregnancy (in a setting where condoms are promoted strongly) or a paucity of men with recent partner pregnancy.
We conducted in-depth, qualitative, individual interviews to explore reproductive decision-making, sexual transmission risk understanding and practices, and periconception risk understanding and practices [
Participants were recruited from March through July 2010 via purposive sampling from patients awaiting clinical consultation. After obtaining informed consent, a gender-concordant research assistant trained in qualitative interviewing techniques interviewed participants in a private setting in isiZulu or English. Interviews lasted approximately 30–90 minutes and were recorded, translated, and transcribed. Participants did not receive compensation for participation.
Transcripts were independently reviewed and coded, and resultant conceptual categories and emergent themes were discussed by the research team using content analysis [
Ethics approvals were obtained from the McCord Hospital Research Ethics Committee (Durban, South Africa) and from the Partners Healthcare Institutional Review Board (Boston, USA).
Baseline demographic data, HIV history, reported partner HIV status, and reproductive history for 30 female and 20 male participants are shown in Table
Study population characteristics.
Characteristics | Women |
Men |
---|---|---|
Age (years) |
|
|
Completed matric or above† | 22 (73%) | 12 (60%) |
Employed | 19 (63%) | 15 (75%) |
Years since HIV diagnosis |
|
|
Currently on ART/ARVs | 21 (70%) | 17/20 (85%) |
HIV-negative (versus unknown status) partner‡ | 14 (46%) | 13 (65%) |
Disclosed HIV status to partner* | 23 (79%) | 15 (78%) |
Pregnancy or partner pregnancy in the past year | 30 (100%) | 3 (16%) |
Pregnancy or partner pregnancy after HIV-diagnosis | 22 (73%) | 2 (11%) |
Pregnancies, including current |
|
— |
Live births |
|
— |
Currently living children |
|
|
*Women—father of referent pregnancy. Men—current or most recent sexual partner.
We have presented a conceptual framework for considering factors that impact periconception risk behavior [
Most participants indicated that they had been informed by a HCW that they should seek advice when they were ready to conceive. In some cases, participants communicated that this advice might help minimize transmission to a child, and in some cases to a partner. This awareness was related to general information shared by counselors during routine ARV adherence training sessions (group adherence training sessions prior to ART initiation are routine in South Africa), regardless of the participant’s fertility goals at the time.
While most participants were aware that they should approach a healthcare worker prior to conception, few sought, or received safer conception advice. Participants described several barriers to accessing reproductive counseling prior to conception including fear of judgment from nurses and financial challenges.
Additional barriers may be related to dyadic factors. For example, participants described that they were told to seek reproductive counseling at the ARV clinic with their partners. However, about a third of participants had not disclosed his/her HIV status to their partner, making this scenario unlikely. Further, about a third of the women in this sample described the referent pregnancy as unplanned.
Participants reported a range of information received from providers. At one end of the spectrum, some participants had not received advice about options for having children since their HIV diagnosis, including in the setting of expressing plans for having children.
Others had received helpful safer conception information from doctors or nurses at PMTCT, ARV, and gynecology clinics. Risk reduction strategies that participants had learned included artificial insemination, intercourse timed to peak fertility, manual insemination (for male—uninfected couples—the uninfected male ejaculates into a condom or other container and the semen is inserted into the woman’s vaginal canal via a syringe or reversed condom), sperm washing, and intercourse with lubrication (to avoid abrasions).
From our sample, many male participants had engaged with a HCW around discussions of safer conception or had sought out information from the internet, relatives, or other news sources.
These qualitative data suggest that HIV-infected patients are increasingly aware of reproductive counseling opportunities. Many participants understood that HCWs may have valuable advice to offer to facilitate safer conception and were open to seeking this advice. While few participants had sought advice, some participants had received safer conception advice from healthcare encounters.
Prior studies suggest that the majority of HIV-infected patients are not receiving reproductive counseling and are reluctant to engage with healthcare workers to discuss reproductive plans [
Many participants reported the expectation that they could access detailed counseling if they returned to the clinic when they were ready to have a child. From work by our group and others, several facts of periconception practice make this clinical approach precarious. Waiting to talk to a provider until one is ready to have a child eliminates the opportunity to discuss the risks of having children in order to
Furthermore, asking individuals or couples to return when they are ready to have children presupposes conception planning. However, many pregnancies are not explicitly planned [
Expecting a patient to raise the issue of fertility plans on his or her own may be problematic. While not a theme in our data, published data suggest that women and men living with HIV hesitate to reveal fertility plans to HCWs for fear of judgment [
Participants had learned of safer conception strategies from HCWs including artificial insemination, intercourse timed to peak fertility, sperm washing, home manual insemination, and intercourse with lubrication to avoid abrasions. The frequency with which sperm washing and artificial insemination was raised is interesting since these are some of the least accessible (geographically, economically) strategies for reducing transmission risk. Simpler risk reduction strategies such as delaying conception until the infected partner is on treatment with suppressed HIV RNA viral load, timing sex without condoms to peak fertility, circumcision for the male partner if he is uninfected, and manual insemination are likely to be more feasible. Our semistructured interview guide was not designed to probe specifically about particular techniques and it is possible that participants were more likely to recall discussions about and have faith in high-tech concepts such as sperm washing compared to behavioral modifications such as timing unprotected sex to peak fertility. In addition, patients may have received limited information, perhaps due to insufficient clinician training on this topic. The WHO guidelines for serodiscordant couples offer some safer conception recommendations, in addition, a more comprehensive guideline was recently published by the Southern African HIV Clinicians Society and will be helpful for clinicians [
We found that, in this sample, male participants were eager to engage with HCWs in order to seek reproductive counseling. Prior data suggests that providers may have less insight into male reproductive intentions [
The main limitations of the data are inherent to qualitative research—findings from this small qualitative sample are meant to generate hypotheses to pursue in future larger scale research. In addition, our participants were attending clinical services at a semiprivate hospital and may not represent the broader population who access public sector care or those who do not access any healthcare. While this clinic does not have a formal program for safer conception counseling, several of the authors previously worked at this clinic which may have heightened some of the clinic providers’ awareness around reproductive counseling for people living with HIV. Finally, patient perspectives of past experiences with provider counseling may not accurately reflect what occurred; provider perspectives are also needed to understand current practices.
These are the first data to explore patient experiences with provider provision of reproductive counseling in KwaZulu Natal, where 41% of women attending antenatal clinics are HIV infected [
The authors would like to thank study participants for their participation and our research assistants for their work on this project. L. T. Matthews received funding support from the American Society of Tropical Medicine and Hygiene/Burroughs-Wellcome Fund Postdoctoral Fellowship in Tropical Infectious Diseases, the Mark and Lisa Schwartz Family Foundation, and a K23 award (NIMH MH095655). D. R. Bangsberg was supported by the Mark and Lisa Schwartz Family Foundation and by a K24 award (NIMH MH087227).