The right to choose parenthood among HIV-infected women and men

HIV and Sexual Dysfunction in Men

Sexual issues tend to go unaddressed in human immunodeficiency virus (HIV) management, although overt sexual dysfunctions are more prevalent in people living with HIV than uninfected people. Erectile dysfunction is the most frequent sexual problem, with a prevalence of 30–50% even in men <40 years of age, but other issues such as loss of libido and ejaculatory disorders should not be overlooked. Peculiar factors related to HIV infection (e.g., fear of virus transmission, changes in body image, HIV-related comorbidities, HIV distress and stigma), alongside classical factors non-related to HIV, should be considered when approaching sexual problems in HIV patients. For this reason, the diagnostic and therapeutic workout of sexual dysfunction in the context of HIV requires a multidisciplinary approach, involving specialists in both infectious diseases and sexual medicine. This narrative review presents an overview of current knowledge on sexual dysfunction in HIV men, deepening the factors driving and taking part in these issues, providing advice for the clinical approach, and underlining the importance of caring for sexual health to improve the quality of life of HIV patients.

Societal and individual drivers of fertility desires and intentions among people living with HIV: a cross sectional study of HIV clinic attendees in Soweto, South Africa

Background

High proportion of people living with HIV (PLHIV) who are in the prime of their reproductive years desire to have children. There are limited studies that explore the range of fertility intentions for PLHIV. This study investigated the fertility desires and intentions of PLHIV and the associated factors.

Methods

This was a cross-sectional study of 442 PLHIV receiving antiretroviral treatment (ART) in health facilities in Soweto, an urban township that is situated in the City of Johannesburg in South Africa. STATA version 13 was used to analyze the data.

Results

The participants' mean age was 36.3 years, 70% were females, 79.6% had at least one biological child, and 36% had 3+ children. Almost half (47%) expressed the desire for children, saying that this was because they had no biological children, or their partners wanted children, or they wanted children of a particular sex, or were feeling healthy after taking ART. An increased fertility desire was associated with absence of biological children (AOR = 5.06, 95% CI: 2.11–12.1) and with being married (AOR = 2.63, 95% CI: 1.31–5.27). A decreased fertility desire was associated with being aged 36+ (AOR = 2.63, 95% CI: 1.31–5.27), having primary education (AOR = 0.11, 95% CI: 0.01–1.30) and having ≥4 years of ART duration (AOR = 0.45, 95% CI: 0.24–0.81).

Conclusion

Individual factors played a significant role in shaping the fertility desires of PLHIV in this setting. The high desire for children underscore the need to integrate reproductive health services in HIV and AIDS care and treatment services and develop safer conception programmes to help PLHIV to conceive and have children safely.

Fertility desire and associated factors among people living with HIV in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Increased Anti-Retroviral Therapy (ART) coverage improves health status and the survival of people living with Human Immunodeficiency Virus (HIV) as a result, reproductive health needs of the clients are increased. As part of continuum HIV care, understanding fertility desire and reproductive health care needs of HIV positive peoples will play paramount role in planning and delivering appropriate health services. The finding of studies conducted on the fertility desire and associated factors among People Living with HIV in Ethiopia presented inconclusive. Therefore, this study aimed to assess the pooled prevalence of fertility desire and associated factors among people living with HIV in Ethiopia.

METHODS

A total of 26 studies conducted in Ethiopia were included in this Meta-analysis. Pub Med, HINARI, Google scholar and Google data bases were searched. Data from the included articles were extracted using a standardized data extraction tool. The included studies were analyzed using a random effects meta-analysis model. Analysis was done Using STATA version 14 statistical software. Heterogeneity was assessed statistically using the standard Chi-square, I^2. The association between fertility desire and factors were examined using a random effects model.

RESULT

In this meta-analysis, the pooled prevalence of fertility desire in Ethiopia is 42.21% (95%CI 39.18, 45.25). Fertility desire is significantly associated with sex: being female (OR = 0.71,95%CI 0.57,0.86), partners desire (OR = 16.8, 95% CI: 9.45, 29.88), not having child (OR = 5.46 95%CI 4.24, 7.040), age < 30(OR = 2.34, 95%CI 2.10, 2.60), formal education (OR = 1.31 95%CI 1.09, 1.59)). However, use of family planning, residence, and Knowledge on Prevention of Mother to Child Transmission and disclosure status didn't show association with fertility desire.

CONCLUSION

In this finding, significant people of living with HIV have a desire to have a child. The finding showed the need to strengthen fertility desire and reproductive health care needs of HIV positive peoples. Therefore, strengthening the integration of fertility related issues with HIV continuum care will play a paramount role in averting risky sexual behaviors and Prevention of Mother to Child Transmission among peoples on ART.

HIV incidence, pregnancy, and implementation outcomes from the Sakh'umndeni safer conception project in South Africa: a prospective cohort study

BACKGROUND

Safer conception strategies empower individuals trying to conceive to minimise HIV transmission risk to partners and potential children; however, effectiveness data are scarce. We aimed to assess adoption of safer conception methods and HIV and pregnancy outcomes from Sakh'umndeni, a novel safer conception service in South Africa.

METHODS

In this prospective cohort study, the Sakh'umndeni clinical cohort at Witkoppen Cinic in Johannesburg (South Africa) enrolled adults aged at least 18 years who were trying to conceive and in relationships with an HIV-positive partner. Couples who were pregnant at enrolment or had been previously diagnosed as infertile were excluded. Participants received safer conception care by a nurse, including antiretroviral therapy (ART) for HIV-positive partners, pre-exposure prophylaxis (PrEP) for HIV-negative partners, counselling around timed condomless sex, or syringes for self-insemination. Primary outcomes were pregnancy incidence and HIV transmission to partners and infants. We estimated time to first pregnancy using Kaplan-Meier curves; pregnancy and HIV incidence were estimated as events per person-years of risk.

FINDINGS

Between July 16, 2013, and April 5, 2017, 526 individuals (334 women and 192 men) from 334 partnerships enrolled. 162 (48%) of 334 couples were serodifferent, 149 (45%) were HIV-positive seroconcordant, and 23 (7%) were an HIV-positive woman and an unknown status male partner. At enrolment, 176 (61%) of 287 HIV-positive women and 60 (46%) of 131 HIV-positive men were virally suppressed (<50 copies per mL). Among the safer conception strategies, ART was initiated by 73 (91%) of 80 HIV-positive participants not on ART and PrEP was initiated by 28 (28%) of 101 HIV-negative participants. 2719 follow-up visits were completed, and 99 pregnancies were observed in 89 women. Pregnancy incidence was 41·2 per 100 person-years (95% CI 33·4-50·7); 25 (28%) of 89 pregnancies with a known outcome were miscarried or terminated because of risk to the mother. Pregnancy incidence was 79·0 per 100 person-years (95% CI 49·8-125·4) among HIV-negative women and 36·7 per 100 person-years (29·1-46·3) among HIV-positive women. At the time of pregnancy, viral suppression among women was high (68 [87%] of 78 women had viral loads of <50 copies per mL and 77 [99%] had viral loads of <1000 copies per mL). No horizontal or vertical HIV transmission events were observed.

INTERPRETATION

Safer conception strategies empowered couples to safely conceive. Pregnancy incidence among service users was high. Integration of safer conception counselling could promote HIV prevention and linkage to care.

FUNDING

US Agency for International Development; UJMT Consortium/Fogarty International Center, US National Institutes of Health (NIH); and Johns Hopkins University Center for AIDS Research (NIH).

Clients' experiences utilizing a safer conception service for HIV affected individuals: implications for differentiated care service delivery models

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 < 50, 50–79 and ≥ 80 respectively. Comparisons of scores were made across safer conception visits attended.

Results

Among 692 clients utilizing safer conception services, 120 (17%) were sampled for the process evaluation; sub-sample participant characteristics were similar to the overall cohort. Clients gave a mean score of ≥90-points for each question assessing service acceptability and 96% (114/119) indicated a high perceived value (scores ≥80) for regular safer conception attendance until conception. Fifty-eight percent (n = 70) of clients reported learning something new during the visit completed the day of the survey, though acquisition of new information tended to decrease as visits increased (p = 0.09). In terms of safer conception strategies, 80% of clients reported high levels of knowledge on the impact of antiretroviral treatment (ART) and viral suppression on HIV transmission, 67% reported high levels of knowledge of the importance of STI screening and 56% regarding limiting condomless sex to days of peak fertility; 34% in sero-different relationships reported high pre-exposure prophylaxis (PrEP) knowledge. Self-efficacy varied by safer conception methods and was similar across study visits.

Conclusions

Clients perceived high value from their safer conception visits and preferred regular attendance until conception, however we observed a plateau in knowledge and self-efficacy across subsequent visits after initially attending safer conception care. More intensive services may be appropriate for certain clients based on clinical circumstances, but many couples may potentially receive a ‘lighter touch’ approach while still minimizing HIV transmission risks.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0718-5) contains supplementary material, which is available to authorized users.

Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study

BACKGROUND

Preventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya.

METHODS

Two hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used.

RESULTS

Seventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winner. FP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant "while using FP": all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices.

CONCLUSIONS

WLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing.

TRIAL REGISTRATION

Integra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862 .

Factors influencing reproductive choices of HIV positive individuals attending primary health care facilities in a South African health district

BACKGROUND

There is global recognition of the reproductive health rights of people living with HIV (PLHIV). The aim of this research study was to explore the reproductive choices, and the factors influencing these choices, of HIV positive patients attending primary health care (PHC) facilities in the Ekurhuleni health district of the Gauteng Province of South Africa.

METHODS

During 2013, a cross-sectional survey was conducted in the Ekurhuleni health district. At each of three randomly selected community health centres, a random sample of HIV positive patients was selected. After informed consent was obtained, trained fieldworkers administered a structured questionnaire that elicited information on socio-demographics, reproductive choices and knowledge of reproductive options. Survey data were analysed using STATA® 13.

RESULTS

The majority of survey participants (n = 430) were female (70%) and unemployed (57%). The mean age of participants was 36.4 years (SD 8.6): 40.8 years (SD 8.7) for men and 34.5 years (SD7.8) for women. Among survey participants, 46% expressed a desire for children (95% CI: 41.4-50.9). In the multiple logistic regression analysis, predictors of desire for children were age less than 49 years, marriage or living together, and no biological children. The odds of wanting children was 16.48 [95% CI: 5.94-45.74] times higher for PLHIV without children, compared with those with two or more children, while for those less than 25 years, the odds of wanting children was 0.78 [95% CI: 0.23-2.59] compared with those older than 50 years. The PLHIV knowledge on the available reproductive options was limited, with the majority relying on the guidance of the health workers.

CONCLUSION

Health care providers at PHC level should be educated to address the reproductive health needs of PLHIV. These aspects should be reflected in provincial and national health policies.

Emtonjeni-A Structural Intervention to Integrate Sexual and Reproductive Health into Public Sector HIV Care in Cape Town, South Africa: Results of a Phase II Study

Integration of sexual and reproductive health within HIV care services is a promising strategy for increasing access to family planning and STI services and reducing unwanted pregnancies, perinatal HIV transmission and maternal and infant mortality among people living with HIV and their partners. We conducted a Phase II randomized futility trial of a multi-level intervention to increase adherence to safer sex guidelines among those wishing to avoid pregnancy and adherence to safer conception guidelines among those seeking conception in newly-diagnosed HIV-positive persons in four public-sector HIV clinics in Cape Town. Clinics were pair-matched and the two clinics within each pair were randomized to either a three-session provider-delivered enhanced intervention (EI) (onsite contraceptive services and brief milieu intervention for staff) or standard-of-care (SOC) provider-delivered intervention. The futility analysis showed that we cannot rule out the possibility that the EI intervention has a 10 % point or greater success rate in improving adherence to safer sex/safer conception guidelines than does SOC (p = 0.573), indicating that the intervention holds merit, and a larger-scale confirmatory study showing whether the EI is superior to SOC has merit.

A Novel Safer Conception Counseling Toolkit for the Prevention of HIV: A Mixed-Methods Evaluation in Kisumu, Kenya

Safer conception strategies can prevent HIV transmission between HIV-discordant partners while allowing them to conceive. However, HIV care providers in sub-Saharan Africa report they are not trained in safer conception, and patients are not routinely offered safer conception services. This mixed-methods pilot study evaluated the impact, acceptability, and feasibility of a novel Safer Conception Counseling Toolkit among providers and patients in Kenya. We enrolled 20 HIV-positive women, 10 HIV-discordant couples, and 10 providers from HIV care and treatment clinics. Providers completed questionnaires before/after training, and then counseled HIV-affected patients. Change in patient knowledge was assessed before/after counseling. Qualitative interviews were conducted among providers and patients. The Toolkit was associated with large, significant increases in patient knowledge, and provider confidence, knowledge, and favorable attitudes toward safer conception counseling; 20% felt confident before versus 100% after training (p < 0.01).

Pregnancy desire and dual method contraceptive use among people living with HIV attending clinical care in Kenya, Namibia and Tanzania

AIM

To describe factors associated with pregnancy desire and dual method use among people living with HIV in clinical care in sub-Saharan Africa.

DESIGN

Sexually active HIV-positive adults were enrolled in 18 HIV clinics in Kenya, Namibia and Tanzania. Demographic, clinical and reproductive health data were captured by interview and medical record abstraction. Correlates of desiring a pregnancy within the next 6 months, and dual method use [defined as consistent condom use together with a highly effective method of contraception (hormonal, intrauterine device (IUD), permanent)], among those not desiring pregnancy, were identified using logistic regression.

RESULTS

Among 3375 participants (median age 37 years, 42% male, 64% on antiretroviral treatment), 565 (17%) desired a pregnancy within the next 6 months. Of those with no short-term fertility desire (n=2542), 686 (27%) reported dual method use, 250 (10%) highly effective contraceptive use only, 1332 (52%) condom use only, and 274 (11%) no protection. Respondents were more likely to desire a pregnancy if they were from Namibia and Tanzania, male, had a primary education, were married/cohabitating, and had fewer children. Factors associated with increased likelihood of dual method use included being female, being comfortable asking a partner to use a condom, and communication with a health care provider about family planning. Participants who perceived that their partner wanted a pregnancy were less likely to report dual method use.

CONCLUSIONS

There was low dual method use and low use of highly effective contraception. Contraceptive protection was predominantly through condom-only use. These findings demonstrate the importance of integrating reproductive health services into routine HIV care.

Barriers to communication between HIV care providers (HCPs) and women living with HIV about child bearing: A qualitative study

OBJECTIVES

In the context of HIV clinical care, open discussion regarding sexual health and reproductive plans has become increasingly relevant. The aim of this paper is to explore barriers to communication between providers and women living with HIV regarding childbearing.

METHODS

In-depth interviews (IDIs) were conducted with 48 HIV infected women receiving ART at 7 different HIV clinics providing comprehensive HIV care services in four districts in Uganda, between July and August 2012. All women were aware of their HIV diagnosis prior to pregnancy or had given birth while living with HIV.

RESULTS

Four themes emerged describing barriers to communication, from the HIV-positive women's point of view: (i) provider indifference or opposition to childbearing post HIV diagnosis, (ii) anticipation of negative response from provider, (iii) provider's emphasis on 'scientific' facts, (iv) 'accidental pregnancy'.

CONCLUSION

Existing evidence regarding effective provider-patient communication should be considered for its application for reproductive counseling among HIV infected women.

PRACTICE IMPLICATIONS

These data demonstrate the need for current counseling guidelines to explore approaches that encourage open, non-judgmental, non-directive discussions with HIV positive individuals around their reproductive desires and intentions in a health care setting.

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

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.

Advancing the sexual and reproductive health and human rights of women living with HIV: a review of UN, regional and national human rights norms and standards

Introduction

The right to sexual and reproductive health (SRH) is an essential part of the right to health and is dependent upon substantive equality, including freedom from multiple and intersecting forms of discrimination that result in exclusion in both law and practice. Nonetheless, general and specific SRH needs of women living with HIV are often not adequately addressed. For example, services that women living with HIV need may not be available or may have multiple barriers, in particular stigma and discrimination. This study was conducted to review United Nations Human Rights Council, Treaty Monitoring Bodies and Special Rapporteur reports and regional and national mechanisms regarding SRH issues of women living with HIV. The objective is to assess areas of progress, as well as gaps, in relation to health and human rights considerations in the work of these normative bodies on health and human rights.

Methods

The review was done using keywords of international, regional and national jurisprudence on findings covering the 2000 to 2014 period for documents in English; searches for the Inter-American Commission on Human Rights and national judgments were also conducted in Spanish. Jurisprudence of UN Treaty Monitoring Bodies, regional mechanisms and national bodies was considered in this regard.

Results and discussion

In total, 236 findings were identified using the search strategy, and of these 129 were selected for review based on the inclusion criteria. The results highlight that while jurisprudence from international, regional and national bodies reflects consideration of some health and human rights issues related to women living with HIV and SRH, the approach of these bodies has been largely ad hoc and lacks a systematic integration of human rights concerns of women living with HIV in relation to SRH. Most findings relate to non-discrimination, accessibility, informed decision-making and accountability. There are critical gaps on normative standards regarding the human rights of women living with HIV in relation to SRH.

Conclusions

A systematic approach to health and human rights considerations related to women living with HIV and SRH by international, regional and national bodies is needed to advance the agenda and ensure that policies and programmes related to SRH systematically take into account the health and human rights of women living with HIV.

Fertility Decision-Making Among Kenyan HIV-Serodiscordant Couples Who Recently Conceived: Implications for Safer Conception Planning

HIV-serodiscordant couples often choose to attempt pregnancy despite their HIV transmission risk. Optimizing delivery of HIV risk reduction strategies during peri-conception periods (i.e., safer conception) requires understanding how HIV-serodiscordant couples approach fertility decisions. We conducted 36 in-depth individual interviews with male and female partners of Kenyan heterosexual HIV-serodiscordant couples who recently conceived. Transcripts were analyzed by gender and HIV serostatus using open coding. Matrices were used to identify patterns and emerging themes. Most participants expressed acceptance of being in an HIV-serodiscordant couple and affirmed their resilience to live with serodiscordance and achieve their fertility goals. Overall, while the goal for childbearing was unchanged, conception became an urgent desire so that both partners could experience childrearing together while the HIV-infected partner was still healthy. Children also add value to the relationship, and multiple children were a commonly expressed desire. Couples' desires dominated those of individual partners in fertility decision-making, but male preferences were more influential when the individual desires differed. Values and preferences of the couple as a unit may mediate fertility decision-making in HIV-discordant couples. Thus, it is important that safer conception programs include both partners when appropriate and consider the relationship context during risk reduction counseling and when recommending risk reduction interventions.

Reproductive desires of men and women living with HIV: implications for family planning counselling

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.

Community perceptions of childbearing and use of safer conception strategies among HIV-discordant couples in Kisumu, Kenya

Introduction

Safer conception strategies (SCS) have the potential to decrease HIV transmission among HIV-discordant couples who desire children. Community perceptions of SCS may influence the scale-up and uptake of these services, but little is known about how communities will react to these strategies. Without community support for SCS, their success as an HIV prevention tool may be limited. The objective of this study is to characterize community perceptions of SCS for HIV-discordant couples in Kisumu, Kenya, to inform ongoing and future safer conception intervention studies in low-resource settings.

Methods

We conducted six focus group discussions and 11 in-depth-interviews in Kisumu, Kenya, among a diverse group (N=59) of community members, including men, women, youth (age 19–25), community health workers and local leaders. An iterative qualitative analysis using a grounded theory approach was employed.

Results and discussion

All participants emphasized the importance of childbearing in their society and the right to have children, regardless of an individual's HIV status. While most participants believed that HIV-discordant couples should be allowed to have children, they discussed several barriers to the uptake of SCS such as HIV-related stigma, fear of HIV transmission to the uninfected partner and child, fear of unfamiliar medical procedures and lack of information among community members and health care providers about HIV prevention interventions that allow safer conception. Access to information, community experiences with successful safer conception interventions, healthcare provider training, male engagement and community mobilization may help overcome these barriers. Though assisted reproduction strategies generated the most negative reactions from participants, our results suggest that with education and explanation of these services, participants express interest in these strategies and want them to be offered in their community.

Conclusions

Many community members noted a need and desire for safer conception education and services in Kisumu. However, community barriers such as fear, stigma and lack of information should be addressed before safer conception interventions can be successfully implemented and delivered. Further research focused on community education, male engagement and healthcare provider training is a crucial next step in delivering safer conception in this region.

Sexual and reproductive health needs of HIV-positive people in Tehran, Iran: a mixed-method descriptive study

BACKGROUND

People Living with HIV (PLHIV) are highly stigmatized and consequently hard-to-access by researchers and importantly, public health outreach in Iran, possibly due to the existing socio-cultural situation in this country. The present study aimed to evaluate the sexual and reproductive health needs of PLHIV in Tehran, the capital of Iran.

METHODS

As a mixed-method descriptive study, this project was conducted in 2012 in Tehran, Iran. In this study, we evaluated and discussed socio-demographic characteristics, family and social support, sexual behaviors, fertility desires and needs, PMTCT services, contraceptive methods, unintended pregnancy and safe abortion, and Pap smear tests among 400 participants referring to the behavioral disorders consulting centers.

RESULTS

Of the sample 240 (60%) were male and 160 (40%) were female. About 50% of women and 40% of men were 25-34 years old. More than 60% of men and 96% of women were married, while more than 50% of the participants had HIV-positive spouses at the time of study. According to the results, fertility desire was observed among more than 30% of female and 40% of male participants. Results of the in-depth interviews indicate that the participants are not satisfied with most of the existing services offered to address their sexual and reproductive health needs.

CONCLUSION

Despite the availability of services, most of sexual and reproductive health needs of the PLHIV are overlooked by the health system in Iran. Paying attention to sexual and reproductive health needs of PLHIV in Iran not only protects their right to live long and healthy lives, but also may prevent the transmission of HIV from the patients to others within the community.

Pregnancy intent among a sample of recently diagnosed HIV-positive women and men practicing unprotected sex in Cape Town, South Africa

BACKGROUND

Sexual and reproductive health (SRH) services for HIV-positive women and men often neglect their fertility desires. We examined factors associated with pregnancy intent among recently diagnosed HIV-positive women (N = 106) and men (N = 91) who reported inconsistent condom use and were enrolled in an SRH intervention conducted in public sector HIV care clinics in Cape Town.

METHODS

Participants were recruited when receiving their first CD4 results at the clinic. All reported unprotected sex in the previous 3 months. Logistic regression identified predictors of pregnancy intent for the total sample and by gender.

RESULTS

About three fifths of men and one fifth of women reported intent to conceive in the next 6 months. In the full-sample multiple regression analysis, men [adjusted odds ratio (AOR = 6.62)] and those whose main partner shared intent to conceive (AOR = 3.80) had significantly higher odds of pregnancy intent; those with more years of education (AOR = 0.81) and more biological children (AOR = 0.62) had lower odds of intending pregnancy. In gender-specific analyses, partner sharing pregnancy intent was positively associated with intent among both men (AOR = 3.53) and women (AOR = 13.24). Among men, odds were lower among those having more biological children (AOR = 0.71) and those unemployed (AOR = 0.30). Among women, relying on hormonal contraception was negatively associated with intent (AOR = 0.08), and main partner knowing her HIV status (AOR = 5.80) was positively associated with intent to conceive.

CONCLUSIONS

Findings underscore the importance of providing integrated SRH services, and we discuss implications for clinical practice and care.

Health care provider perspectives on pregnancy and parenting in HIV-positive individuals in South Africa

BACKGROUND

Within the health system, limited attention is given to supporting the fertility and parenting desires on HIV-positive people. In this study, we explore health care providers' knowledge and perspectives on safer conception and alternate parenting strategies for HIV-positive people.

METHODS

Between November 2007 and January 2008, in-depth interviews were conducted with 28 health care workers involved in providing HIV and/or antiretroviral services at public sector clinics in Cape Town, South Africa. Views on sexual and reproductive health services, pregnancy, childbearing and parenting in HIV-positive men and women were explored using a semi-structured interview guide. Data were analyzed using a thematic approach.

RESULTS

Providers recognized the sexual and reproductive rights of HIV-positive individuals, but struggled with the tension between supporting these rights and concerns about spreading infection. Limited knowledge of safer conception methods constrained their ability to counsel and support clients in realizing fertility desires. Providers believed that parenting alternatives that do not maintain biological and cultural linkage are unlikely to be acceptable options.

CONCLUSIONS

Health care provider training and support is critical to providing comprehensive sexual and reproductive health care and meeting the fertility desires of HIV-positive people.

Parenting and child outcomes of HIV-infected African American mothers: a literature review

Parenting young children while living with HIV is an important public health concern. This article reviews maternal HIV and the impact it has on the parenting experience of African American mothers. Because living with HIV has been considered a family illness, the Family Systems Model provided a framework for this article. The model demonstrated an important link between maternal HIV and its impact on the health and wellbeing of not only the mother and her children, but her parenting and family roles as well. Research has documented an association between maternal HIV and negative parent-child outcomes among African American mothers. I examined studies on parenting and child outcomes among African American mothers living with HIV. The review assists in conceptualizing parenting with HIV as an area of increasing importance in health services delivery to HIV-infected African American mothers who are caring for young children.

Incidence and predictors of pregnancy among a cohort of HIV-positive women initiating antiretroviral therapy in Mbarara, Uganda

Objective

Many people living with HIV in sub-Saharan Africa desire biological children. Implementation of HIV prevention strategies that support the reproductive goals of people living with HIV while minimizing HIV transmission risk to sexual partners and future children requires a comprehensive understanding of pregnancy in this population. We analyzed prospective cohort data to determine pregnancy incidence and predictors among HIV-positive women initiating antiretroviral therapy (ART) in a setting with high HIV prevalence and fertility.

Methods

Participants were enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort of HIV-positive individuals initiating ART in Mbarara. Bloodwork (including CD4 cells/mm³, HIV viral load) and questionnaires (including socio-demographics, health status, sexual behavior, partner dynamics, HIV history, and self-reported pregnancy) were completed at baseline and quarterly. Our analysis includes 351 HIV-positive women (18–49 years) who enrolled between 2005–2011. We measured pregnancy incidence by proximal and distal time relative to ART initiation and used multivariable Cox proportional hazards regression analysis (with repeated events) to identify baseline and time-dependent predictors of pregnancy post-ART initiation.

Results

At baseline (pre-ART initiation), median age was 33 years [IQR: 27–37] and median prior livebirths was four [IQR: 2–6]. 38% were married with 61% reporting HIV-positive spouses. 73% of women had disclosed HIV status to a primary sexual partner. Median baseline CD4 was 137 cells/mm³ [IQR: 81–207]. At enrolment, 9.1% (31/342) reported current pregnancy. After ART initiation, 84 women experienced 105 pregnancies over 3.8 median years of follow-up, yielding a pregnancy incidence of 9.40 per 100 WYs. Three years post-ART initiation, cumulative probability of at least one pregnancy was 28% and independently associated with younger age (Adjusted Hazard Ratio (AHR): 0.89/year increase; 95%CI: 0.86–0.92) and HIV serostatus disclosure to primary sexual partner (AHR: 2.45; 95%CI: 1.29–4.63).

Conclusions

Nearly one-third of women became pregnant within three years of initiating ART, highlighting the need for integrated services to prevent unintended pregnancies and reduce periconception-related risks for HIV-infected women choosing to conceive. Association with younger age and disclosure suggests a role for early and couples-based safer conception counselling.

Serodiscordance and disclosure among HIV-positive pregnant women in the Southwestern United States

The prevalence of HIV-positive pregnant women in relationships with HIV-negative men in the United States is unclear. The purpose of this study was to calculate the prevalence of HIV-positive pregnant women with a serodiscordant (HIV-negative) partner within a single clinic population, assess disclosure of their HIV status, and examine factors associated with disclosure. All HIV-positive pregnant women who received prenatal care at the Harris County Hospital District Women's Program at Northwest Health Center in Houston TX between 1/1/2006 and 4/1/2011 were identified. Data were obtained from electronic medical records. Prevalence of serodiscordance and disclosure was calculated, and predictors of disclosure were evaluated. We identified 212 HIV-positive pregnant women. About 40% had a serodiscordant partner, and 34% had a partner with an unknown HIV status. Disclosure occurred in over 90% of women with a serodiscordant partner and in 68% of women with partners whose HIV status was unknown. Among pregnant women who knew their HIV status prior to the current pregnancy and had a serodiscordant partner, 92% reported disclosing their status prior to conception. Our data indicated that serodiscordant relationships are common in our clinic population. Suboptimal disclosure rates were observed, especially among women who have a partner with an unknown HIV status. Further research is needed to evaluate the prevalence of serodiscordance and disclosure in other United States populations.

Antiretrovirals and safer conception for HIV-serodiscordant couples

PURPOSE OF REVIEW

Many men and women living with HIV and their uninfected partners attempt to conceive children. HIV-prevention science can be applied to reduce sexual transmission risk while respecting couples' reproductive goals. Here we discuss antiretrovirals as prevention in the context of safer conception for HIV-serodiscordant couples.

RECENT FINDINGS

Antiretroviral therapy (ART) for the infected partner and pre-exposure prophylaxis (PrEP) for the uninfected partner reduce the risk of heterosexual HIV transmission. Several demonstration projects suggest the feasibility and acceptability of antiretroviral (ARV)s as periconception HIV-prevention for HIV-serodiscordant couples. The application of ARVs to periconception risk reduction may be limited by adherence.

SUMMARY

For male-infected (M+F-) couples who cannot access sperm processing and female-infected (F+M-) couples unwilling to carry out insemination without intercourse, ART for the infected partner, PrEP for the uninfected partner, combined with treatment for sexually transmitted infections, sex limited to peak fertility, and medical male circumcision (for F+M couples) provide excellent, well tolerated options for reducing the risk of periconception HIV sexual transmission.

Systematic review of HIV transmission between heterosexual serodiscordant couples where the HIV-positive partner is fully suppressed on antiretroviral therapy

BACKGROUND

The risk of sexual HIV transmission in serodiscordant couples when the HIV-positive partner has full virologic suppression on combination antiretroviral therapy (cART) is debated. This study aims to systematically review observational studies and randomized controlled trials (RCTs), evaluating rates of sexual HIV transmission between heterosexual serodiscordant couples when the HIV-positive partner has full suppression on cART.

METHODS AND FINDINGS

We searched major bibliographic databases to November 2012 for relevant observational studies and RCTs without language restrictions. Conference proceedings, key journals and bibliographies were also searched. Studies reporting HIV transmission rates, cART histories and viral loads of the HIV-positive partners were included. Two reviewers extracted methodologic characteristics and outcomes. Of 20,252 citations, 3 studies met all eligibility criteria with confirmed full virologic suppression in the HIV-positive partner. We included 3 additional studies (2 cohort studies, 1 RCT) that did not confirm viral suppression in the HIV-positive partner at transmission in a secondary meta-analysis. Methodologic quality was reasonable. The rate of transmission in the 3 studies confirming virologic suppression was 0 per 100 person-years (95% CI = 0-0.05), with low heterogeneity (I(2) = 0%). When we included the 3 studies that did not confirm virologic suppression, the rate of transmission was 0.14 per 100 person-years (95%CI = 0.04-0.31) (I(2) = 0%). In a sensitivity analysis including all 6 studies, the rate of transmission was 0 per 100 person-years (95%CI = 0-0.01) after omitting all transmissions with known detectable or unconfirmed viral loads, as full suppression in these cases was unlikely. Limitations included lack of data on same-sex couples, type of sexual intercourse (vaginal vs. anal), direction of HIV transmission, exact viral load at the time of transmission, sexually transmitted infections (STI) rates, and extent of condom use.

CONCLUSIONS

Our findings suggest minimal risk of sexual HIV transmission for heterosexual serodiscordant couples when the HIV-positive partner has full viral suppression on cART with caveats regarding information on sexual intercourse type, STIs, and condom use. These findings have implications when counseling heterosexual serodiscordant couples on sexual and reproductive health. More research is needed to explore HIV transmission risk between same-sex couples.

Reproductive decision-making and periconception practices among HIV-positive men and women attending HIV services in Durban, South Africa

Understanding reproductive decisions and periconception behavior among HIV-discordant couples is important for designing risk reduction interventions for couples who choose to conceive. In-depth interviews were conducted to explore reproductive decision-making and periconception practices among HIV-positive women with recent pregnancy (n = 30), and HIV-positive men (n = 20), all reporting partners of negative or unknown HIV-status, and attending HIV services in Durban, South Africa. Transcripts were coded for categories and emergent themes. Participants expressed strong reasons for having children, but rarely knew how to reduce periconception HIV transmission. Pregnancy planning occurred on a spectrum ranging from explicitly intended to explicitly unintended, with many falling in between the two extremes. Male fertility desire and misunderstanding serodiscordance contributed to HIV risk behavior. Participants expressed openness to healthcare worker advice for safer conception and modified risk behavior post-conception, suggesting the feasibility of safer conception interventions which may target both men and women and include serodiscordance counseling and promotion of contraception.

Differences in the Nonuse of any Contraception and Use of Specific Contraceptive Methods in HIV Positive and HIV Negative Rwandan Women

Contraception can reduce the dual burden of high fertility and high HIV prevalence in sub-Sahara Africa, but significant barriers remain regarding access and use. We describe factors associated with nonuse of contraception and with use of specific contraceptive methods in HIV positive and HIV negative Rwandan women. Data from 395 HIV-positive and 76 HIV-negative women who desired no pregnancy in the previous 6 months were analyzed using univariate and multivariate logistic regression models to identify clinical and demographic characteristics that predict contraceptive use. Differences in contraceptive methods used were dependent on marital/partner status, partner's knowledge of a woman's HIV status, and age. Overall, condoms, abstinence, and hormonal methods were the most used, though differences existed by HIV status. Less than 10% of women both HIV+ and HIV− used no contraception. Important differences exist between HIV-positive and HIV-negative women with regard to contraceptive method use that should be addressed by interventions seeking to improve contraceptive prevalence.

A conceptual framework for understanding HIV risk behavior in the context of supporting fertility goals among HIV-serodiscordant couples

Integrated reproductive health services for people living with HIV must address their fertility intentions. For HIV-serodiscordant couples who want to conceive, attempted conception confers a substantial risk of HIV transmission to the uninfected partner. Behavioral and pharmacologic strategies may reduce HIV transmission risk among HIV-serodiscordant couples who seek to conceive. In order to develop effective pharmaco-behavioral programs, it is important to understand and address the contexts surrounding reproductive decision-making; perceived periconception HIV transmission risk; and periconception risk behaviors. We present a conceptual framework to describe the dynamics involved in periconception HIV risk behaviors in a South African setting. We adapt the Information-Motivation-Behavioral Skill Model of HIV Preventative Behavior to address the structural, individual and couple-level determinants of safer conception behavior. The framework is intended to identify factors that influence periconception HIV risk behavior among serodiscordant couples, and therefore to guide design and implementation of integrated and effective HIV, reproductive health and family planning services that support reproductive decision-making.

Between a rock and a hard place: stigma and the desire to have children among people living with HIV in northern Uganda

BACKGROUND

HIV-related stigma, among other factors, has been shown to have an impact on the desire to have children among people living with HIV (PLHIV). Our objective was to explore the experiences of HIV-related stigma among PLHIV in post-conflict northern Uganda, a region of high HIV prevalence, high infant and child mortality and low contraception use, and to describe how stigma affected the desires of PLHIV to have children in the future.

METHODS

Semi-structured interviews were conducted with 26 PLHIV in Gulu district, northern Uganda. The interviews, conducted in Luo, the local language, were audio recorded, transcribed and then translated into English. Thematic data analysis was undertaken using NVivo8 and was underpinned by the "Conceptual Model of HIV/AIDS Stigma".

RESULTS

HIV-related stigma continues to affect the quality of life of PLHIV in Gulu district, northern Uganda, and also influences PLHIV's desire to have children. PLHIV in northern Uganda continue to experience stigma in various forms, including internal stigma and verbal abuse from community members. While many PLHIV desire to have children and are strongly influenced by several factors including societal and cultural obligations, stigma and discrimination also affect this desire. Several dimensions of stigma, such as types of stigma (received, internal and associated stigma), stigmatizing behaviours (abusing and desertion) and agents of stigmatization (families, communities and health systems), either directly, or indirectly, enhanced or reduced PLHIV's desire to have more children.

CONCLUSIONS

The social-cultural context within which PLHIV continue to desire to have children must be better understood by all health professionals who hope to improve the quality of PLHIV's lives. By delineating the stigma process, the paper proposes interventions for reducing stigmatization of PLHIV in northern Uganda in order to improve the quality of life and health outcomes for PLHIV and their children.

Discussing childbearing with HIV-infected women of reproductive age in clinical care: a comparison of Brazil and the US

Despite long term access to highly active antiretroviral therapy in Brazil and the US, little is known about women's communication with their HIV provider regarding childbearing or the unmet need for reproductive counseling. We utilized identical survey questions to collect data from HIV-infected women of reproductive age in Rio de Janeiro (n = 180) and Baltimore (n = 181). We conducted univariate analyses to compare findings between samples of women and multivariate logistic regression to determine factors associated with childbearing desires, childbearing intentions, and provider communication among the combined sample of women (n = 361). Over one-third of women in Rio de Janeiro and nearly one-half of women in Baltimore reported the desire for future childbearing. Nevertheless, the majority of women in clinical care had not discussed future childbearing with their HIV provider. Even in countries with an advanced approach to HIV care, we found low and inadequate communication between providers and female patients about childbearing.

Safer conception interventions for HIV-affected couples: implications for resource-constrained settings

Developing and testing safer conception methods that reduce HIV transmission to HIV-seronegative partners in serodiscordant couples and reduce superinfection in HIV-seroconcordant couples is a crucial but often unaddressed component of HIV prevention programs. Most research has focused on developed-world settings, where "high-technology" assisted reproduction techniques are used for HIV-serodiscordant couples in which the male is HIV-infected. There is a dearth of research on safer conception methods for HIV-seropositive women and "low-technology" harm-reduction strategies for HIV-affected couples, including vaginal insemination for HIV-seropositive women and natural conception methods for HIV-seroconcordant and -serodiscordant couples. This review summarizes international studies of safer conception interventions for HIV-affected couples, with a focus on feasibility in public-sector health settings where assisted reproductive technology is not readily available. Given that such low-technology options are feasible in most settings, well-designed, prospective interventions offering low-technology safer conception methods need to be developed and tested.

The African Women's Protocol: bringing attention to reproductive rights and the MDGs

Andrew Gibbs and colleagues discuss the African Women's Protocol, a framework for ensuring reproductive rights are supported throughout the continent and for supporting interventions to improve women's reproductive health, including the MDGs.