Beyond HIV-serodiscordance: Partnership communication dynamics that affect engagement in safer conception care

Abstract

IntroductionWe explored acceptability and feasibility of safer conception methods among HIV-affected couples in Uganda.MethodsWe recruited HIV-positive men and women on antiretroviral therapy (ART) (‘index’) from the Uganda Antiretroviral Rural Treatment Outcomes cohort who reported an HIV-negative or unknown-serostatus partner (‘partner’), HIV-serostatus disclosure to partner, and personal or partner desire for a child within two years. We conducted in-depth interviews with 40 individuals from 20 couples, using a narrative approach with tailored images to assess acceptability of five safer conception strategies: ART for the infected partner, pre-exposure prophylaxis (PrEP) for the uninfected partner, condomless sex timed to peak fertility, manual insemination, and male circumcision. Translated and transcribed data were analyzed using thematic analysis.Results11/20 index participants were women, median age of 32.5 years, median of 2 living children, and 80% had HIV-RNA <400 copies/mL. Awareness of HIV prevention strategies beyond condoms and abstinence was limited and precluded opportunity to explore or validly assess acceptability or feasibility of safer conception methods. Four key partnership communication challenges emerged as primary barriers to engagement in safer conception care, including: (1) HIV-serostatus disclosure: Although disclosure was an inclusion criterion, partners commonly reported not knowing the index partner’s HIV status. Similarly, the partner’s HIV-serostatus, as reported by the index, was frequently inaccurate. (2) Childbearing intention: Many couples had divergent childbearing intentions and made incorrect assumptions about their partner’s desires. (3) HIV risk perception: Participants had disparate understandings of HIV transmission and disagreed on the acceptable level of HIV risk to meet reproductive goals. (4) Partnership commitment: Participants revealed significant discord in perceptions of partnership commitment. All four types of partnership miscommunication introduced constraints to autonomous reproductive decision-making, particularly for women. Such miscommunication was common, as only 2 of 20 partnerships in our sample were mutually-disclosed with agreement across all four communication themes.ConclusionsEnthusiasm for safer conception programming is growing. Our findings highlight the importance of addressing gendered partnership communication regarding HIV disclosure, reproductive goals, acceptable HIV risk, and commitment, alongside technical safer conception advice. Failing to consider partnership dynamics across these domains risks limiting reach, uptake, adherence to, and retention in safer conception programming.

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

“…Another barrier to SCS access among HIV affected couples is challenges with HIV serostatus disclosure [22, 24, 45, 49, 50, 64]. Prior studies have shown that serostatus disclosure can be facilitated by couples’ HIV counseling and testing which provides a counselor-mediated venue for serostatus disclosure and is also an opportunity to reach HIV-affected couples to discuss their fertility goals [81, 82] and potentially improve their ability to communicate about safer conception.…”

Factors Associated with Pregnancy Intentions Amongst Postpartum Women Living with HIV in Rural Southwestern Uganda

“…The importance of male partners in influencing reproductive decision-making has been described. Generally, and regardless of serostatus, male partners have been shown to have great influence on having another child, but receive minimal counselling about the benefits of spacing, options for safer pre and conception practices [ 8 , 25 – 27 ]. Nieves and colleagues also noted that partner’s fertility desire was independently associated with women’s contraceptive use [ 3 ].…”

“…Men in Uganda have often been regarded as unsupportive of their partner’s use of family planning [ 28 ] and some studies show that poor communication within partnerships may make it challenging for men to be involved [ 8 ]. In our study, 78% of the women reported that their partners knew they were on family planning, the rest choosing not to disclose it, while 14% of the sexual partners reportedly disapproved their partners using contraception.…”

“…Other studies report up to 85% of pregnancies occurring within 3 years following ART initiation as unwanted [ 6 ]. Although increasing desires to have children are reported amongst mutually-disclosed serodiscordant couples in Uganda [ 7 ], couples often disagree in their perceptions of each partner’s plans for pregnancy, understandings of HIV transmission, and acceptable level of HIV risk to meet their reproductive goals [ 8 ]. While supported pregnancies are an important part of life for many HIV-affected couples, unwanted and/or unplanned pregnancies can lead to poor maternal and child outcomes including perinatal HIV transmission, pregnancy complications, and increased economic burden of care for self and others among others.…”

Prevalence and factors associated with fertility desires/intentions among individuals in HIV‐serodiscordant relationships: a systematic review of empirical studies

“…Unequal gender power dynamics within sex-opposite couples have led men, regardless of who is living with HIV, to play a dominant role in decisions about fertility, determining if, how and when to conceive [9,20]. For example, Matthews et al [19], in their study with PLWH on ART who reported a partner living without HIV or a partner with unknown serostatus, suggested that many couples made incorrect assumptions about their partner's desires, had disparate understandings about HIV transmission and disagreed on the acceptable level of HIV risk to meet reproductive goals. This study also reinforced the importance of assessing and supporting disclosure of HIV status between partners, which is required for effective use of some safer conception options, as timed intercourse [9].…”