Discussing reproductive goals with healthcare providers among women living with HIV in Canada: the role of provider gender and patient comfort

Abstract

Antiretroviral therapy effectively prevents sexual and vertical transmission of HIV. Yet, some women living with HIV report having unmet needs for reproductive health care. This study measured the prevalence of women discussing reproductive goals with any current healthcare provider and assessed the effect of the current HIV care provider’s gender on such discussions and whether comfort was a mediator. We analysed baseline and 18-month survey data from 533 women living with HIV enrolled in the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) (2013–2017), a community-based participatory study, restricting the analysis to participants aged 16–45 years. We used causal mediation analysis to estimate direct and indirect effects of the gender of one’s HIV care provider on reproductive discussions, incorporating mediating and interaction effects of women having any provider with whom they felt comfortable discussing reproductive goals. Between the baseline and 18-month follow-up surveys, 34.3% (183/533) of women discussed their reproductive goals with a healthcare provider. Having a woman HIV care provider was associated with a 1.18 excess relative risk (ERR) of discussion (95%CI: 0.15, 2.20). The mediating effect of comfort was primarily explained by the fact that those participants with women providers felt more comfortable discussing their reproductive goals compared to participants with men providers, accounting for 66% (95%CI: 32%, 99%) of the total effect. Findings support that HIV provider gender affects women’s comfort and whether they discuss reproductive goals, which must be acknowledged and addressed in care delivery.

Factors and Priorities Influencing Satisfaction with Care among Women Living with HIV in Canada: A Fuzzy Cognitive Mapping Study

“…Fear of HIV-related stigma has been found to impact interactions with HIV clinics and staff [ 35 ]. The importance of patient-provider relationships, including those developed with female healthcare providers, has been shown to affect health outcomes, such as discussing reproductive goals with healthcare providers and sexual and perinatal wellbeing among women living with HIV [ 12 , 36 ]. Healthcare provider gender has been shown to predict health outcomes outside of HIV care [ 37 , 38 ].…”

“…Women’s perceptions of their care environments affect not only HIV outcomes, but also sexual and reproductive health, an aspect of care particularly neglected. Women living with HIV who report feeling comfortable with healthcare providers are more likely to discuss their reproductive goals with their care providers [ 12 ]. Although frameworks recognizing the need for gendered care approaches exist [ 13 , 14 ], few studies have examined the care preferences and priorities of women living with HIV.…”

Key recommendations for developing a national action plan to advance the sexual and reproductive health and rights of women living with HIV in Canada

“… 51 CHIWOS findings reveal among women living with HIV of reproductive age and potential (16–49 years), 29% intend to become pregnant in future, 41% do not, and 30% are unsure or preferred not to say. 52 Such intentions are highly dynamic with two-fifths of women changing their pregnancy intentions within 3 years of follow-up. 53 Despite these varying reproductive intentions, nearly half of women living with HIV had never discussed their reproductive goals with a healthcare provider since being diagnosed with HIV.…”

“… 53 Despite these varying reproductive intentions, nearly half of women living with HIV had never discussed their reproductive goals with a healthcare provider since being diagnosed with HIV. 52 Also, 42% reported they did not currently have a healthcare provider they felt comfortable speaking to about reproductive goals. The impact of gaps in reproductive health care is evident in findings that one-quarter of women living with HIV in the CHIWOS study reported at least one pregnancy after HIV diagnosis; and of all pregnancies within the study’s timeframe, 61% were reported as unintended.…”

Patterns of changing pregnancy intentions among women living with HIV in Canada

“…Healthcare providers should be aware of the social and structural factors that influence the relationship between pregnancy intention and pregnancy outcome. Despite the large proportion of women whose intentions changed over the study, analyses of data from the same cohort found that reproductive discussions are not routine and account for the largest measured gap in comprehensive healthcare for women living with HIV [ 17 , 49 ]. Supporting the uptake of effective contraception and clinical follow-up is particularly important to help women living with HIV prevent unwanted and unplanned pregnancies [ 35 ] and improve uptake of long-acting and hormonal contraceptives, which has been observed to be lower among women living with HIV in Canada compared to the general population [ 19 ].…”