Supporting HIV prevention and reproductive goals in an HIV-endemic setting: taking safer conception services from policy to practice in South Africa

Abstract

Introduction: Safer conception care encompasses HIV care, treatment and prevention for persons living with HIV and their partners who desire children. In 2012, South Africa endorsed a progressive safer conception policy supporting HIV-affected persons to safely meet reproductive goals. However, aside from select research-supported clinics, widespread implementation has not occurred. Using South Africa as a case study, we identify key obstacles to policy implementation and offer recommendations to catalyse expansion of these services throughout South Africa and further afield.Discussion: Four key implementation barriers were identified by combining authors’ safer conception service delivery experiences with available literature. First, strategic implementation frameworks stipulating where, and by whom, safer conception services should be provided are needed. Integrating safer conception services into universal test-and-treat (UTT) and elimination-of-mother-to-child-transmission (eMTCT) priority programmes would support HIV testing, ART initiation and management, viral suppression and early antenatal/eMTCT care engagement goals, reducing horizontal and vertical transmissions. Embedding measurable safer conception targets into these priority programmes would ensure accountability for implementation progress. Second, facing an organizational clinic culture that often undermines clients’ reproductive rights, healthcare providers’ (HCP) positive experiences with eMTCT and enthusiasm for UTT provide opportunities to shift facility-level and individual attitudes in favour of safer conception provision. Third, safer conception guidelines have not been incorporated into HCP training. Combining safer conception with “test-and-treat” training would efficiently ensure that providers are better equipped to discuss clients’ reproductive goals and support safer conception practices. Lastly, HIV-affected couples remain largely unaware of safer conception strategies. HIV-affected populations need to be mobilized to engage with safer conception options alongside other HIV-related healthcare services.Conclusion: Key barriers to widespread safer conception service provision in South Africa include poor translation of policy into practical and measurable implementation plans, inadequate training and limited community engagement. South Africa should leverage the momentum and accountability associated with high priority UTT and eMTCT programmes to reinvigorate implementation efforts by incorporating safer conception into implementation and monitoring frameworks and associated HCP training and community engagement activities. South Africa’s experiences should be used to inform policy development and implementation processes in other HIV high-burden countries.

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].…”

Factors associated with desired fertility among HIV-positive women and men attending two urban clinics in Lilongwe, Malawi

“…Responses highlight the prevalence of community misconceptions regarding MTCT, HIV progression, and their possible influence on family planning goals among people living with HIV. Previous studies have outlined additional barriers to implementation of safer conception, including health care provider (HCP) training and HCPs sharing positive experiences with elimination of MTCT and safer conception methods during universal test-and-treat [ 28 , 29 ]. The ability to act on improved knowledge is also crucial: access to ART/PMTCT services in Uganda increased the desire for future childbearing among women [ 25 ].…”

Subfertility among HIV-affected couples in a safer conception cohort in South Africa

“…Understanding the prevalence and determinants of subfertility among HIV-affected couples is thus essential for decreasing HIV transmission resulting from prolonged periods of HIV exposure and to maximize the effectiveness of safer conception services. 1,27 The objective of this analysis is to determine the burden and predictors of subfertility among HIV-affected couples seeking safer conception care.…”