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

Abstract

We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception interventions. Following PRISMA guidelines, we searched fifteen electronic databases using the following inclusion criteria: SCS research in HIV-affected couples; published after 2007; in sub-Saharan Africa; primary research; peer-reviewed; and addressed a primary topic of interest (SCS availability, feasibility, and acceptability, and/or education and promotion). Researchers independently reviewed each study for eligibility using a standardized tool. We categorize studies by their topic area. We identified 41 studies (26 qualitative and 15 quantitative) that met inclusion criteria. Reviewed SCSs included: antiretroviral therapy (ART), pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC). SCS were largely unavailable outside of research settings, except for general availability (i.e., not specifically for safer conception) of ART and VMMC. SCS acceptability was impacted by low client and provider knowledge about safer conception services, stigma around HIV-affected couples wanting children, and difficulty with HIV disclosure in HIV-affected couples. Couples expressed desire to learn more about SCS; however, provider training, patient education, SCS promotions, and integration of reproductive health and HIV services remain limited. Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge. SCS are not yet widely available to HIV-affected African couples. Successful implementation of SCS requires that providers receive training on effective SCS and provide couple-based safer conception counseling to improve disclosure and communication around fertility intentions and reproductive health.

Safer conception for female sex workers living with HIV in Dar es Salaam, Tanzania: Cross-sectional analysis of needs and opportunities in integrated family planning/HIV services

“…This study corroborates and substantiates the burgeoning research documenting the desire for children among women living with HIV, and the indisputable need and opportunity to provide explicit safer conception counseling and services to these women [1][2][3][4][5][6][7]. At the same time, among women who did not want to get pregnant within the next two years, 10% were neither using condoms consistently, nor using another modern contraceptive method.…”

“…The advent of effective antiretroviral treatment (ART) has ushered in an era in which women living with HIV can lead full and healthy lives, including having children if they so desire [1][2][3]. Studies around the world consistently demonstrate that many women living with HIVbetween 20% and 50%-want to have children [3][4][5][6][7]. There now is an array of biomedical and behavioral "safer conception" strategies to help these women get pregnant, while minimizing risk of onward transmission to seronegative partners and infants.…”

“…For example, the current scientific consensus that "undetectable = untransmittable (U = U)" [8] underlies a highly effective safer conception strategy: women living with HIV will not transmit the virus to seronegative partners once they are on treatment and virally suppressed for at least six months [1]. Other lower-and higher-technology safer conception strategies include timing condomless sex to the HIV-positive woman's fertile days, manual self-insemination with an HIV-negative man's sperm, pre-exposure prophylaxis (PrEP) to prevent HIV acquisition by seronegative partners, voluntary medical male circumcision, sperm donation, and sperm washing [1,3,9,10].…”

“…In the past decade, worldwide, there has been a steady increase in research, service delivery, and advocacy to support women living with HIV to make informed decisions about whether, when, and how to become mothers [1,3,[11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. National normative guidelines on safer conception have been issued in Canada [26], South Africa [9], and the United Kingdom [27], and the World Health Organization delineates strategies for achieving safe and healthy pregnancy in its guidelines on the sexual and reproductive health and rights of women living with HIV [10].…”

Implementation of a comprehensive safer conception intervention for HIV‐serodiscordant couples in Kenya: uptake, use and effectiveness

“…Many recent safer conception studies and public programmes have shown good uptake of safer conception strategies, including ART and PrEP . To the best of our knowledge, ours is the first study to estimate the effectiveness of a safer conception intervention on HIV transmission risk.…”