“It really proves to us that we are still valuable”: Qualitative research to inform a safer conception intervention for men living with HIV in South Africa

Abstract

Objective Many men living with HIV want to have children. Opportunities to reduce periconception HIV transmission include antiretroviral therapy as prevention, pre-exposure prophylaxis, limiting condomless sex to peak fertility, and sperm processing. Whether men have knowledge of or want to adopt these strategies remains unknown. Methods We conducted focus group discussions (FGDs) with men accessing HIV care in South Africa in 2014 to inform a safer conception intervention for men. Eligible men were 25–45 years old, living with HIV, not yet accessing treatment, and wanting to have a child with an HIV-negative or unknown serostatus female partner (referred to as the “desired pregnancy partner”). FGDs explored motivations for having a healthy baby, feasibility of a clinic-based safer conception intervention, and acceptability of safer conception strategies. Data were analyzed using thematic analysis. Results Twelve participants from three FGDs had a median age of 37 (range 23–45) years, reported a median of 2 (range 1–4) sexual partners, and 1 (range 1–3) desired pregnancy partner(s). A third (N = 4) had disclosed HIV-serostatus to the pregnancy partner. Emergent themes included opportunities for and challenges to engaging men in safer conception services. Opportunities included enthusiasm for a clinic-based safer conception intervention and acceptance of some safer conception strategies. Challenges included poor understanding of safer conception strategies, unfamiliarity with risk reduction [versus “safe” (condoms) and “unsafe” (condomless) sex], mixed acceptability of safer conception strategies, and concerns about disclosing HIV-serostatus to a partner. Conclusions Men living with HIV expressed interest in safer conception and willingness to attend clinic programs. Imprecise prevention counseling messages make it difficult for men to conceptualize risk reduction. Effective safer conception programs should embrace clear language, e.g. undetectable = untransmittable (U = U), and support multiple approaches to serostatus disclosure to pregnancy partners.

Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana

“…While medical male circumcision and ART use for viral suppression were well-known SC methods, most other methods, including PrEP, were known by 40% of participants or less. Other studies in sub-Saharan Africa have similarly found low but varying information levels about SC methods [ 23 , 25 , 79 ]. While PrEP is a powerful SC option for sero-different couples, the low knowledge of PrEP is not surprising.…”

“…Our prior qualitative work in Botswana also found apathy about ART use among WLHIV, making SC approaches to compliment ART use even more relevant [ 34 ]. Similarly, a South African study among MLHIV who desired children found that men wanted to avoid using ART as treatment as prevention [ 79 ]. Clients would benefit from having information about a wide range of SC methods since one approach will not work for all couples and providing options supports reproductive choice [ 22 , 66 , 79 ].…”

“…Similarly, a South African study among MLHIV who desired children found that men wanted to avoid using ART as treatment as prevention [ 79 ]. Clients would benefit from having information about a wide range of SC methods since one approach will not work for all couples and providing options supports reproductive choice [ 22 , 66 , 79 ]. Therefore, an intervention aimed at improving SC uptake would need to educate PLHIV about a range of SC techniques.…”

“…Male partners likely need more information about SC methods, and identifying SC methods that men are comfortable with is critical to their use. While a study in South Africa with MLHIV who desired children found that men were enthusiastic for a clinic-based SC intervention [ 79 ], they also found structural barriers to participating in clinic-based interventions [ 87 ]. HIV-negative men in sero-different relationships may be reluctant to visit health centers for SC information and counseling.…”

“…In our prior qualitative work in Botswana, we found that WLHIV anticipated stigma from healthcare providers and were afraid to discuss their fertility desires with them [ 38 , 66 ]. Qualitative studies from Uganda and South Africa have similarly found that anticipated stigma is a barrier to seeking SC services [ 85 , 93 ] and that MLHIV feel they cannot discuss SC with healthcare providers [ 79 ]. Given these qualitative findings, it is not surprising that that anticipated stigma had a negative impact on motivation to use SC.…”