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

Abstract

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 HIVserodiscordant 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.

A Systematic Review of the Current Status of Safer Conception Strategies for HIV Affected Heterosexual Couples in Sub-Saharan Africa

“…The review found that SCS were largely unavailable in sub-Saharan Africa outside of research settings, except for general availability (i.e., not for safer conception specifically) of ART and VMMC. Availability of SCS methods was greatest in public health facilities providing general services for people living with HIV [20–26, 31, 36, 39–44, 47–50, 56, 58, 59, 62, 63, 66–68]. More advanced or expensive strategies such as sperm washing, or PrEP remain unavailable in most public health facilities due to cost and lack of provider training [14–17, 23].…”

Gendered differences in the perceived risks and benefits of oral PrEP among HIV-serodiscordant couples in Kenya

“…T. Montgomery et al, 2012). Findings from the parent study cohort, published elsewhere (Ngure et al, 2014), reveal a similar dynamic in childbearing decisions; when men wanted a child but their wives did not, they used language such as “she must” and “I will force her.” Such intense divisions of power have been known to result in domestic violence against women (Pintye et al, 2015; Wingood & DiClemente, 2000), and HIV seropositive women are at higher risk of such abuse than their seronegative peers in both Kenya (Fonck et al, 2005; Onsomu et al, 2014) and Uganda (Emusu et al, 2009; Were et al, 2011). These patterns provide a possible explanation for why the seropositive men in this study were vocal about their control of household decisions and silent about the potential for taking PrEP to be burdensome to their spouses: they may experience their HIV diagnosis as a loss of masculine control, which they are subsequently attempting to re-establish in their homes.…”

Fertility desires and preferences for safer conception strategies among people receiving care for HIV at a publicly-funded clinic in Seattle, WA

“…Multiple clinical guidelines, including those from World Health Organization (2012), the American College of Obstetrics and Gynecologists (2014), and the US Panel on the Treatment of HIV Infected Pregnant Women and Prevention of Perinatal Transmission (2016), recommend PrEP as a safer conception strategy for individuals at high risk of HIV, and previous studies have demonstrated that couples affected by HIV welcome the opportunity to augment ART use with PrEP during pregnancy attempts. (Heffron, Mugo, et al, 2016; Matthews et al, 2014; Ngure et al, 2014; Ngure et al, 2016; Pintye et al, 2015; Seidman et al, 2016) Reported experience with PrEP was low among participants in our study with an HIV uninfected partner. Awareness of PrEP as a safer conception strategy was moderate among reproductive age participants with fertility desires and many identified potential barriers to HIV uninfected partners using PrEP during pregnancy attempts.…”

“…Effective management of HIV with antiretroviral therapy has enabled people living with HIV to achieve full life expectancy, including satisfying desires for pregnancy and family (Deeks, Lewin, & Havlir, 2013; Finocchario-Kessler et al, 2012; Massad et al, 2004; Mujugira et al, 2013; Oguntibeju, 2012; Pintye et al, 2015; Samji et al, 2013; Sharma et al, 2007). The preconception period, when couples intentionally forgo condoms to achieve pregnancy, can be accompanied by increased HIV transmission risk (Heffron, Pintye, Matthews, Weber, & Mugo, 2016), especially when viremia is not fully suppressed in the partner living with HIV.…”