Implementation of a safer conception service for HIV-affected couples in South Africa

Abstract

Objective To describe the development and implementation of a safer conception service in a resource-limited setting. Methods Qualitative work to inform the design of a safer conception service was conducted with clients and providers at Witkoppen Health and Welfare Centre, a primary health center in Johannesburg, South Africa. Services began in July 2013, for HIV-affected participants planning conception within six months and included counseling about timed unprotected intercourse and home-based self-insemination, early initiation of combined antiretroviral therapy (cART) for HIV-infected individuals, pre-exposure prophylaxis (PrEP) for HIV-uninfected partners and circumcision for men. Participants were enrolled into an implementation science study evaluating method uptake, acceptability, and pregnancy and HIV transmission outcomes. Results Findings to-date from 51 qualitative participants and 128 clinical cohort participants (82 women and 46 men, representing 82 partnerships) are presented. All men were accompanied by female partners, whereas 56% of women attended with their male partner. Fifteen of 46 couples (33%) were in confirmed serodiscordant relationships, however of the 36 additional women attending alone, 56% were unaware of their partners’ HIV status or believed them to be HIV-uninfected. The majority of HIV-infected women (86%) and men (71%) were on cART at enrollment, however only 47% on cART were virally suppressed. Timed unprotected intercourse, self-insemination and cART were common choices for participants; few elected PrEP. Conclusions Lessons learned from early implementation demonstrate feasibility of safer conception services, however reaching discordant couples, cART-naïve infected partners, and men remain challenges. Creating demand for safer conception services among those at highest risk for HIV transmission is necessary.

Periconception HIV Risk Behavior Among Men and Women Reporting HIV-Serodiscordant Partners in KwaZulu-Natal, South Africa

“…However, this paper and work by others (6,40,62,94) suggest that disclosure, pregnancy planning, and communication with partner are critical first steps that must be supported before successful implementation of specific safer conceptions strategies can take place on a broad scale. Mutually-disclosed HIV-serodiscordant couples with well-articulated fertility goals are an important but minority population in South Africa (39,98). There is an evidence-based imperative to integrate comprehensive safer conception counseling into a diverse range of services accessed by persons living with HIV and their partners to improve accessibility of this information (37,99,100) and explore how to maximize acceptability and feasibility.…”

“…South Africa's national clinical guidelines on fertility planning recommend these risk-reduction strategies (except for PrEP, which is not yet available in the public sector) for serodiscordant couples who want to conceive their own children (36,37). Recent data suggest that these strategies are, however, not widely recommended by South African providers (38) but uptake was high in an implementation project (39). …”

Fertility-related research needs among women at the margins

“…Overview of fertility-related research areas for women of reproductive age. 23(45): [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46] many factors aside from HIV influence decisions to terminate pregnancy, and that abortion is less common among women living with HIV in the antiretroviral era. 3,26 Further knowledge regarding post-abortion care and approaches to effectively integrate HIV and post-abortion care services should be expanded.…”

“…44 Although work is beginning to emerge in this area, key gaps include evaluation of the safety and efficacy of low-cost safer conception methods for HIV prevention, adherence to conception methods, time-topregnancy across methods, infertility figures, and comparative effectiveness of safer conception approaches including timed unprotected sex limited to peri-ovulatory periods, manual self-insemination, and unrestricted condomless sex while using antiretrovirals. 45,46 Several implementation questions also remain unanswered related to the optimal delivery of safer conception programmes, such as scale-up feasibility, costs, service utilization, fidelity and impact. Furthermore, for HIV negative women trying to conceive with HIV positive male partners, or other women at high-risk for HIV acquisition, guidance is urgently needed on the safety of vaginal and oral pre-exposure prophylaxis (PrEP) when trying to conceive, during pregnancy and throughout breastfeeding, as condom negotiation may not always be possible within certain relationships.…”

Coming of age? Women’s sexual and reproductive health after twentyone years of democracy in South Africa

“…These include pre-and post-exposure prophylaxis treatment as prevention and "lower-tech" safer conception methods such as timed intercourse and manual self-insemination with an HIV uninfected male partner's sperm. 59 Research-supported safer conception services are being successfully provided in Johannesburg, Durban and Cape Town, 60,61 and need to be scaled up.…”