Search

ABSTRACT Adherence to antiretroviral therapy (ART) remains sub-optimal among pregnant and postpartum women with HIV (PPWH) in high HIV prevalence low resource settings with few effective behavioral interventions. A large body of qualitative literature has established general barriers and facilitators to ART adherence in PPWH at various levels (individual, interpersonal, structural). However, research exploring the underlying behavioral mechanisms of ART adherence in PPWH with objectively verified adherence biomarkers is extremely limited. We conducted 24 in-depth interviews with postpartum women in western Kenya who had linked ART drug concentrations obtained from three dried blood spot samples across the peripartum period. Among PPWH with a low drug concentration ( n  = 13) compared to those with continuously high drug concentrations ( n  = 11), distinct themes emerged related to HIV status disclosure, social support, interactions with the health system, and health beliefs. By combining ART biomarkers with patient reported challenges, there is the potential for real-time interventions to support sustained ART adherence among PPWH and improve maternal and infant health outcomes.

This prospective cohort study investigated the mobility patterns of 200 pregnant and postpartum women living with HIV in South Africa. Participants were enrolled during their third trimester from routine antenatal care near Cape Town, South Africa, and followed for six months postpartum. Quantitative data were collected at enrollment and follow-up. Mobility (self-reported) was common among the participants, despite the brief study period and the concurrent COVID-19 pandemic. While most reported stability in their current residence, 71% had a second main residence, primarily in the Eastern Cape (EC). Participants had a median of two lifetime moves, motivated by work, education, and family life. During the study period, 20% of participants met the study definition of travel (>7 days and >50 km), with trips predominantly to the EC, lasting a median duration of 30 days. Over one-third of participants with other living children reported that these children lived apart from them, with the mother's family being primary caregivers. These findings emphasize the need for targeted interventions to support continuity of care for mobile populations, particularly peripartum women living with HIV. The study contributes valuable insights into mobility dynamics and highlights unique barriers faced by this population, contributing to improved HIV care in resource-limited settings.

Previous maternity experiences may influence subsequent reproductive intentions and motherhood experiences. We used latent class analysis to identify patterns of early motherhood experience reported for the most recent live birth of 905 women living with HIV enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Four indicators were used: difficulties getting pregnant, feelings when finding out pregnancy, feelings during pregnancy, and feelings during the first year postpartum. Most (70.8%) pregnancies analyzed occurred before HIV diagnosis. A four-class maternity experience model was selected: "overall positive experience" (40%); "positive experience with postpartum challenges" (23%); "overall mixed experience" (14%); and "overall negative experience" (23%). Women represented in the "overall negative experience" class were more likely to be younger at delivery, to not know the HIV status of their pregnancy partner, and to report previous pregnancy termination. Women represented in the "positive experience with postpartum challenges" class were more likely to report previous miscarriage, stillbirth or ectopic pregnancy. We found no associations between timing of HIV diagnosis (before, during or after pregnancy) and experience patterns. Recognition of the different patterns of experiences can help providers offer a more adapted approach to reproductive counseling of women with HIV.

Across sub-Saharan Africa, prevention of mother-to-child transmission services are encountering increasing numbers of women already established on antiretroviral therapy (ART) when entering antenatal care. However, there are few data examining ART adherence and HIV viral load in this group. We used multivariable logistic regression models to examine self-reported suboptimal adherence (defined as missed ART doses on ≥2 days during the preceding 30 days), elevated viral load (≥1000 copies/mL), and factors associated with each among women entering antenatal care on ART. Participants were recruited from one primary care clinic in Gugulethu, Cape Town, as part of a larger study of HIV-positive pregnant and postpartum women. Among 482 pregnant women established on ART and enrolled between May 2013 and June 2014 (median age: 31 years; median duration of ART use: 3 years), 15% reported suboptimal adherence and 12% had elevated viral load. After adjustment for age, suboptimal adherence was significantly more common among women who were not married/cohabiting and women who reported a higher level of concern about taking ART; a higher level of adherence self-efficacy was associated with a reduced odds of suboptimal adherence. In a multivariable model, elevated viral load was significantly associated with previous discontinuation of ART, a higher level of concern about taking ART, and report of an unintended pregnancy. Suboptimal adherence and elevated viral load are common among women entering antenatal care already on ART. Our findings highlight specific beliefs and concerns about ART use during pregnancy that should be addressed in counselling messaging, and suggest that family planning should be more effectively integrated into HIV care. Including adherence and viral load monitoring as part of pregnancy planning for women on ART may be important to achieve safer conception and promote healthy pregnancies.

Pregnant women living with HIV represent one of the most high-priority groups for HIV treatment and health assessment. Although social support has been shown to be a protective factor for improved health-related quality of life (HRQoL), and depression and anxiety have been identified as two major causes of psychological distress among people living with HIV, it is still unclear how social support, anxiety, and depression interact to influence HRQoL. The objective of our study was to demonstrate the nature of predictors, direct effects and mediator effects among social support, anxiety, depression symptoms and HRQoL in pregnant women living with HIV. We investigated a total of 101 pregnant women living with HIV in Yunnan province in China from April 2016 to June 2016. All participants completed the Social Support Rating Scale (SSRS), the Chinese version of the Hospital Anxiety and Depression Scales (HADS) and Quality of Life instruments (EuroQoL Five Dimensions Questionnaire, EQ-5D). The relationships between the variables were examined by Pearson's or Spearman's correlation analysis. Predictor effects were tested using separate multiple regressions, controlling for demographic variables and HIV diagnosis variables. Direct and mediation effects of social support on HRQoL were tested using a structural equation model (SEM). Anxiety and depression symptoms were negatively correlated with subjective social support, support utilization, social support and HRQoL. Social support significantly predicted better HRQoL, and anxiety and depression symptoms significantly predicted poorer HRQoL. Anxiety and depression symptoms partially mediated the associations between social support and HRQoL. Anxiety and depression symptoms completely mediated the associations of objective support and support utilization with HRQoL. Interventions to improve HRQoL in pregnant women living with HIV must consider the mediation effect of anxiety and depression symptoms on the association between social support and HRQoL. Social support interventions are valid only when anxiety and depression symptoms are managed effectively.

"Depression (as noted in chart by a physician)" was compared between HIV infected pregnant women and controls. Perinatally HIV-infected (PHIV), non-perinatally HIV-infected (NPHIV), and HIV-uninfected (HIV-U) pregnant women were all compared using a logistic regression model. Overall, HIV-infected women had higher rates of depression than HIV-U, with PHIV women demonstrating a clinically and statistically significant increased risk compared to HIV-U women [adjusted OR: 15.9, 95% CI = 1.8-143.8]. Future studies in larger populations are warranted to confirm these findings and further elucidate mental health outcomes of PHIV and NPHIV pregnant women.

Pregnant women living with HIV (WLHIV) in South Africa (SA) report higher rates of suicidal ideation than those who are HIV uninfected, and antenatal suicidal ideation has been previously associated with adverse maternal and neonatal outcomes. Few studies have attempted to identify correlates and psychosocial predictors of suicidal ideation in this population. In this study, we sought to estimate the prevalence of and identify risk factors for suicidal ideation among pregnant WLHIV in rural SA (N = 673). Thirty-nine percent of women endorsed suicidal ideation (95% CI: 35.2% to 42.3%) and in multivariable logistic regression analysis, suicidal ideation was associated with intimate partner violence and stigma, which interacted to multiplicatively increase the odds of suicidal thoughts. Given the high rates of reported suicidal ideation identified in this sample, and the potential harm to mothers and neonates, suicide risk assessment and management protocols for pregnant WLHIV should be considered for inclusion in the standard of care in rural SA.

This study aimed to describe demographic and psychological characteristics among HIV-infected young women, and to identify knowledge, attitudes, and behaviors associated with conception, with the goal of informing interventions or programmatic decisions regarding preconception counseling methods for young women living with HIV. Behaviorally and perinatally HIV-infected young women (n = 34) were conveniently sampled in Miami, Florida. Participants were asked to complete measures of reproductive knowledge, attitudes toward conception, and risk behaviors, as well as measures of depression and cognitive functioning. Perinatally and behaviorally HIV-infected young women were very similar in important areas of health preconception practices such as conception-related health literacy and conception-related communication with providers. Behaviorally infected women, however, were somewhat more likely to have been pregnant in the past, and had greater knowledge of healthy contraception practices and family planning. Despite the difference among groups, both the perinatally and behaviorally acquired women demonstrated having adequate overall knowledge. Depression was higher and consistent with moderate depression among the behaviorally HIV-infected women in comparison to perinatally infected women. This study found that that despite adequate reproductive knowledge, most young HIV-infected women were not using contraception. Given the consequences of presentation of advanced HIV during pregnancy, the need for both treatment adherence and preconception counseling is essential. Results suggest that interventions or programmatic decisions regarding preconception counseling methods for young women living with HIV are necessary and potentially transferrable between populations., Competing Interests: statement: No potential conflict of interest was reported by the authors.

HIV-related stigma is associated with many psychological challenges; however, minimal research has explored how perceived HIV-related stigma intersects with psychosocial issues that mothers living with HIV may experience including depression, perceived stress and social isolation. The present study aims to describe the correlates and predictors of HIV-related stigma in a cohort of women living with HIV (WLWH) from across Ontario, Canada during pregnancy and early postpartum. From March 2011 to December 2012, WLWH ≥ 18 years (n = 77) completed a study instrument measuring independent variables including sociodemographic characteristics, perceived stress, depression symptoms, social isolation, social support and perceived racism in the third trimester and 3, 6 and 12 months postpartum. Multivariable linear regression was employed to explore the relationship between HIV-related stigma and multiple independent variables. HIV-related stigma generally increased from pregnancy to postpartum; however, there were no significant differences in HIV-related stigma across all study time points. In multivariable regression, depression symptoms and perceived racism were significant predictors of overall HIV-related stigma from pregnancy to postpartum. The present analysis contributes to our understanding of HIV-related stigma throughout the pregnancy-motherhood trajectory for WLWH including the interactional relationship between HIV-related stigma and other psychosocial variables, most notably, depression and racism.

The wider availability of anti-retroviral treatment has brought about an improvement in the immunological situation of human immunodeficiency virus (HIV)-positive individuals, which in turn has led to significant reductions in AIDS-related morbidity and mortality and better quality of life for patients. However, the rate of diagnosis of new cases of HIV among the adult population is on the increase due to high-risk sexual behavior practices, particularly not using condoms, sexual relations with a large number of partners and starting sexual relations at a younger age, with unplanned pregnancies and sexually transmitted infections (STIs), including HIV. For this reason, public health managers have invested considerable effort in recent years in creating STI and HIV prevention programs. Yet, in spite of the implementation of measures for reducing the rates of infection, few studies have been published in Spain comparing individuals living with HIV with the general population about cognitive variables and the link between these variables and high-risk sexual behavior. The objective was to compare a group of individuals living with HIV with another group from the general population in terms of cognitive variables (knowledge about STIs and HIV, concern about STI/HIV and pregnancy, self-efficacy to refuse sexual relations and resilience) and sexual behavior. The sample consisted of 318 adults, 159 were from the general population and 159 were individuals living with HIV. Individuals living with HIV had higher scores for concern about HIV/AIDS, STIs, pregnancy and knowledge of STI/HIV compared with the general population. We concluded that uninfected people who had low and high level of concern about HIV/AIDS began having anal sex at a younger age than those with a medium level of concern. Overall, results indicate that the concern about HIV/AIDS should be addressed in preventive health interventions to minimize the risks of sexual behavior.

Mothers with HIV are at high risk of a range of psychosocial issues that may impact HIV disease progression for themselves and their children. Stigma has also become a substantial barrier to accessing HIV/AIDS care and prevention services. The study objective was to determine the prevalence and severity of postpartum depression (PPD) among women living with HIV and to further understand the impact of stigma and other psychosocial factors in 123 women living with HIV attending prevention of mother-to-child transmission (PMTCT) clinic at Kenyatta National Hospital located in Nairobi, Kenya. We used the Edinburgh Postnatal Depression Scale and HIV/AIDS Stigma Instrument - PLWHA (HASI - P). Forty-eight percent (N = 59) of women screened positive for elevated depressive symptoms. Eleven (9%) of the participants reported high levels of stigma. Multivariate analyses showed that lower education (OR = 0.14, 95% CI [0.04-0.46], p = .001) and lack of family support (OR = 2.49, 95% CI [1.14-5.42], p = .02) were associated with the presence of elevated depressive symptoms. The presence of stigma implied more than ninefold risk of development of PPD (OR = 9.44, 95% CI [1.132-78.79], p = .04). Stigma was positively correlated with an increase in PPD. PMTCT is an ideal context to reach out to women to address mental health problems especially depression screening and offering psychosocial treatments bolstering quality of life of the mother-baby dyad.

Male partner involvement (MPI) has been identified as a priority intervention in programmes for the prevention of mother-to-child transmission (PMTCT) of HIV, but rates of MPI remain low worldwide. This study used a quantitative survey (n=170) and two focus group discussions (FGDs) with 16 HIV-positive pregnant women attending a public sector antenatal care service in Khayelitsha, South Africa, to examine the determinants of high levels of involvement and generate a broader understanding of women's experiences of MPI during pregnancy. Among survey participants, 74% had disclosed their status to their partner, and most reported high levels of communication around HIV testing and preventing partner transmission, as well as high levels of MPI. High MPI was significantly more likely among women who were cohabiting with their partner; who had reportedly disclosed their HIV status to their partner; and who reported higher levels of HIV-related communication with their partner. FGD participants discussed a range of ways in which partners can be supportive during pregnancy, not limited to male attendance of antenatal care. MPI appears to be a feasible intervention in this context, and MPI interventions should aim to encourage male partner attendance of antenatal care as well as greater involvement in pregnancy more generally. Interventions that target communication are needed to facilitate HIV-related communication and disclosure within couples. MPI should remain a priority intervention in PMTCT programmes, and increased efforts should be made to promote MPI in PMTCT.

Women with perinatally acquired HIV (PAH) face unique psychosocial challenges due to the presence of a lifelong chronic illness and often unstable living situations. With advances in HIV treatment, an increasing number of those with PAH are reaching childbearing age and becoming pregnant. Depression may be an important and common factor that complicates both treatment and pregnancy outcomes in this group. We conducted a retrospective cohort study in pregnant patients with PAH to determine if history of depression is associated with nonadherence to antiretroviral therapy (ART). We reviewed charts of women with PAH receiving prenatal care at a single institution from March 1995 to December 2012. ART nonadherence was measured by patient self-report of any missed doses in the third trimester. Demographic, obstetric, and HIV infection characteristics of patients with a history of depression (dPAH) were compared to patients without a history of depression. Nine pregnancies among 6 dPAH women and 14 pregnancies among 12 PAH women without a history of depression were identified. None of the dPAH women reported 100% adherence to ART in the third trimester while 57% of women without a history of depression reported strict adherence (p = 0.04). The mean HIV RNA level at delivery was higher among dPAH women (17,399 vs. 2966 copies/Ml; p = 0.03) and fewer reached an undetectable HIV RNA level (<400 copies/mL) at delivery (p = 0.03). We concluded that a history of depression may contribute to poor medication adherence and treatment outcomes among pregnant women with PAH. Focused attention on diagnosis and treatment of depression in the preconception period may lead to more optimal medication adherence.

Disclosure of one's HIV status can help to improve uptake and retention in prevention of mother-to-child transmission of HIV services; yet, it remains a challenge for many women. This systematic review evaluates disclosure rates among pregnant and postpartum women in sub-Saharan Africa, timing of disclosure, and factors affecting decisions to disclose. PubMed and EMBASE databases were searched to identify relevant studies published between January 2000 and April 2014. Rates of HIV serostatus disclosure to any person ranged from 5.0% to 96.7% (pooled estimate: 67.0%, 95% CI: 55.7%-78.3%). Women who chose to disclose their status did so more often to their partners (pooled estimate: 63.9%; 95% CI: 56.7%-71.1%) than to family members (pooled estimate: 40.1; 95% CI: 26.2%-54.0%), friends (pooled estimate: 6.4%; 95% CI: 3.0%-9.8%), or religious leaders (pooled estimate: 7.1%; 95% CI: 4.3%-9.8%). Most women disclosed prior to delivery. Decisions to disclose were associated with factors related to the woman herself (younger age, first pregnancies, knowing someone with HIV, lower levels of internalized stigma, and lower levels of avoidant coping), the partner (prior history of HIV testing and higher levels of educational attainment), their partnership (no history of domestic violence and financial independence), and the household (higher quality of housing and residing without co-spouses or extended family members). Interventions to encourage and support women in safely disclosing their status are needed.

Improved health outcomes have resulted in people with HIV facing decisions about childbearing. We sought to understand the factors associated with desire for a child among men and women in Malawi. HIV-infected men and women ages 18-40 were invited to participate in a brief interview about fertility desires. Single variable logistic regression was used to evaluate the factors associated with the outcome of fertility desire. Additionally, multiple logistic regression was used to assess the relationship of all the factors together on the outcome of fertility desire. In-depth interviews with women were performed to understand experiences with reproductive health care. A total of 202 brief interviews were completed with 75 men (37.1%) and 127 women (62.9%), with 103 (51.0%) of respondents desiring a child. Being in a relationship (OR: 3.48, 95% CI: 1.58-7.65, p = 0.002) and duration of HIV more than two years (OR: 2.00, 95% CI: 1.08-3.67, p = 0.03) were associated with increased odds of desire for a child. Age 36-40 years (OR: 0.64, 95% CI: 0.46-0.90, p = 0.009) and having a living child (OR: 0.24, 95% CI: 0.07-0.84, p = 0.03) were associated with decreased odds of desire for a child. Seventy percent of women (n = 19 of 27 respondents) completing semistructured interviews who responded to the question about decision-making reported that their male partners made decisions about children, while the remainder reported the decision was collaborative (n = 8, 30%). Eighty-six percent of women (n = 36 of 42 respondents) reported no discussion or a discouraging discussion with a provider about having children. HIV-infected women and men in Malawi maintain a desire to have children. Interventions are needed to integrate safer conception into HIV care, to improve male participation in safer conception counseling, and to empower providers to help patients make decisions about reproduction free of discrimination and coercion.

The objective of the study was to assess the effectiveness of group counseling, using a problem-solving therapy approach, on reducing depressive symptoms and increasing prenatal disclosure rates of HIV status among HIV-positive pregnant women living in Dar es Salaam, Tanzania. A randomized controlled trial was performed comparing a six-week structured nurse-midwife facilitated psychosocial support group with the standard of care. Sixty percent of women in the intervention group were depressed post-intervention, versus 73% in the control group [Relative Risk (RR) = 0.82, 95% confidence interval (CI): 0.67-1.01, p=0.066]. HIV disclosure rates did not differ across the two study arms. However, among those women who disclosed, there was a significantly higher level of overall personal satisfaction with the response to disclosure from family and friends among women in the treatment (88%) compared to the control group (62%; p=0.004). The results indicate reductions in the level of depressive symptoms comparable with major depressive disorder (MDD) for HIV-positive pregnant women participating in a group counseling intervention. Although the psychosocial group counseling did not significantly increase disclosure rates, an improvement in the level of personal satisfaction resulting from disclosure was associated with the intervention. This suggests that the counseling sessions have likely reduced the burden of depression and helped clients better manage partner reactions to disclosure. Public agencies and non-governmental organizations working in Tanzania and similar settings should consider offering structured psychosocial support groups to HIV-positive pregnant women to prevent poor mental health outcomes, promote early childhood development, and potentially impact HIV-related disease outcomes in the long term.

This study examines the societal perceptions and judgements made towards HIV-positive pregnant women when compared with those targeting pregnant women with other medical conditions. One hundred and sixty participants (124 female) were randomly assigned to one of four experimental conditions defined by specific medical condition of the pregnant woman in the vignette (HIV/AIDS, obesity, lung cancer or diabetes). Participants were asked to respond to a variety of items gauging their reaction to the woman and her pregnancy subsequent to reading the scenario. As expected, participants were least approving of the pregnancy of the woman with HIV/AIDS, and they rated her as a less fit parent than the women with the other medical conditions. Subsequent analyses revealed that concern for the health of the child and attributions of responsibility/blame for the medical condition did not account for the differential reactions to the pregnant woman with HIV/AIDS. These findings corroborate the felt stigma and prejudicial attitudes reported by HIV-positive mothers.

Structured interviews were conducted with 224 HIV-positive women diagnosed during pregnancy, at antenatal clinics in Tshwane, South Africa, in order to investigate the use of coping strategies during the first two years after diagnosis. Interviews were conducted between one and four weeks after diagnosis during pregnancy, with three follow-up interviews conducted post-partum. Coping strategies were assessed with an adapted version of the Brief COPE. It was found that active coping was used more often than avoidant coping throughout the study period. Active coping increased over time, while avoidant coping decreased at first but increased again between 6 and 21 months after diagnosis. The most frequently used coping strategies included acceptance, direct action, positive reframing, religion and distraction. At first, women coped through internalised strategies. Over time, outward-focused strategies developed. Avoidant coping patterns differed from previous research indicating that women diagnosed during pregnancy deal with the consequences of HIV after the baby is born. Recommendations for mental health services are made.

Ukraine has one of the highest levels of HIV prevalence in Europe. Provider-initiated HIV testing and counseling (PITC) is routine during antenatal care (ANC) in Ukraine, with nearly all pregnant women receiving HIV testing. National policies state that testing is voluntary, with consent and confidentiality protections, but little is known about actual testing implementation and adherence to these policies. A qualitative study was conducted to explore women's and providers' experiences of HIV testing during ANC, with a focus on consent, counseling, and confidentiality. In-depth interviews were conducted at two urban women's clinics and one semi-urban women's clinic in Donetsk, one of the most HIV-affected regions in Ukraine. Interviews targeted HIV-positive and HIV-negative women recently tested during ANC, as well as health providers involved in administering HIV tests during ANC. Interview analysis revealed gaps between policies and practices, as well as differences in perceptions of aspects of PITC between women and providers. Notable findings included: wide variation in informed consent procedures; providers reporting feeling unequipped to provide adequate counseling; and post-testing practices that may jeopardize patient confidentiality, particularly in the semi-urban site. These findings suggest the need for additional training and support, especially outside major cities, to ensure that HIV testing practices during ANC adhere to Ukrainian policy and global principles regarding PITC.

HIV disclosure is emphasised as an important component of efforts to prevent HIV transmission, including those to prevent transmission from mother to child. Studies which approach disclosure as a dichotomous variable that is either present or absent have generated a significant body of research describing disclosure patterns, antecedents, barriers and consequences. This study joins a growing body of research which explores disclosure as a complex, selective and gradual process occurring within the context of relationships. Using a qualitative, longitudinal ethnographic approach, the study explores HIV-positive women's subjective experience of disclosure and how they make meaning and understand disclosure processes during pregnancy and early motherhood. An interpretative phenomenological analysis of field notes from participant observation and in-depth interview transcripts suggests that women may experience disclosure as a more fluid construct than previously assumed. In contrast to the traditional dichotomous and linear approach to understanding disclosure, the meaning ascribed to disclosure "events" and behaviours was changeable and even reversible over time. These shifts occurred alongside changes in women's internal, interpersonal and material worlds and served important psychological and social functions. The findings have important implications for HIV counsellors working to encourage disclosure in the context of prevention interventions.

Pregnant women who fear or experience HIV-related stigma may not get care for their own health or medications to reduce perinatal transmission of HIV. This study examined factors associated with anticipating and experiencing HIV-related stigma among 1777 pregnant women attending antenatal care clinics in rural Kenya. Women were interviewed at baseline, offered HIV testing and care, and a sub-set was re-interviewed at 4-8 weeks postpartum. Women who were older, had less education, whose husbands had other wives, and who perceived community discrimination against people with HIV had significantly greater adjusted odds of anticipating HIV stigma. Over half of the HIV-positive women interviewed postpartum reported having experienced stigma, much of which was self-stigma. Women experiencing minor depression, and those whose family knew of their HIV status had significantly greater adjusted odds of experiencing stigma. Lack of women's empowerment, as well as depression, may be important risk factors for HIV-related stigma and discrimination.

This paper explores HIV-positive women's accounts of their use and non-use of treatments for the prevention of mother-to-child transmission. In-depth interviews were conducted in 2001 with 34 HIV-positive women who were diagnosed during their childbearing years. This paper reports on the 16 women who gave birth after being diagnosed with HIV. Some women reported experiencing debilitating side-effects of antiretroviral (ARV) therapy, and all were aware that the history of HIV therapy was not one of clear, consistent and benevolent effectiveness. It was evident that women wanted the best outcomes for themselves and their babies. Women represented their role vis-a-vis their children as encompassing protection against a medical fraternity that insisted on the use of ARV and prophylaxis without acknowledging the mothers' concerns about toxicity. From the women's perspective, it made sense not to let their babies become experimental subjects when long-term effects were unknown. To maximise the benefit of ARV therapy to mothers and babies, thereby reducing the risk of vertical transmission, it is imperative to understand a woman's explanation of what therapy means to her, and advisable to presume that she wants the best for her baby. Such an approach will facilitate better communication and encourage clinicians and patients to work towards a shared goal.

Delayed antiretroviral initiation is associated with increased mortality, but individuals frequently delay seeking treatment. To increase early antiretroviral therapy (ART) enrollment of HIV-positive women, antenatal clinics are implementing regular, postpartum CD4 count testing. We examined factors influencing women's utilization of extended CD4 count testing. About 53 in-depth interviews were conducted with nurses, patients, social support persons, and government health officials at three antenatal clinics in Lilongwe, Malawi. Counseling and positive interactions with staff emerged as facilitating factors. Women wanted to know their CD4 count, but didn't understand the importance of early ART initiation. Support from husbands facilitated women's return to the clinic. Reminders were perceived as helpful but ineffectively employed. Staff identified lack of communication, difficulty in tracking, and referring women as barriers. Counseling messages should emphasize the importance of starting ART early. Clinics should focus on male partner involvement, case management, staff communication, and appointment reminders. Follow-up should be offered at multiple service points.

In Karnataka, India only one-third of HIV-infected pregnant women received antiretroviral prophylaxis at delivery in 2007 through the state government's prevention of parent-to-child HIV transmission (PPTCT) program. The current qualitative study explored the role of HIV-associated stigma as a barrier to access PPTCT services in the rural northern Karnataka district of Bagalkot using in-depth interviews and focus group discussions with HIV-infected women who had participated in the PPTCT program, male and female family members, and HIV service providers. Participants discussed personal experiences, community perceptions of HIV, and decision-making related to accessing PPTCT services. They described stigma toward HIV-infected individuals from multiple sources: healthcare workers; community members; family; and self. Stigma-related behaviors were based on fears of HIV transmission through personal contact and moral judgment. Experience and/or fears of discrimination led pregnant women to avoid using PPTCT interventions. Government, cultural, and historical factors are described as the roots of much the stigma-related behavior in this setting. Based on these formative data, PPTCT program planners should consider further research and interventions aimed at diminishing institutional and interpersonal HIV-associated stigma experienced by pregnant women.

Informed consent has historically been a cornerstone to ensuring autonomy during HIV testing. However, recent changes to global guidance on HIV testing have led to substantial debate on what policy provisions are necessary to ensure that consent remains meaningful in the context of testing. Despite disproportionate rates of testing during pregnancy, pregnant women's perspectives on the HIV testing process are underrepresented in the testing discourse. This study explores women's experiences with HIV testing and the consent process in a public antenatal clinic in South Africa. Qualitative interviews with 25 women were conducted at the clinic at either an antenatal visit or an infant immunization visit that followed HIV testing. Interviews were transcribed, translated, and coded for analysis. Women were categorized into one of the three groups based on their perceptions of choice in consenting for an HIV test. Matrices were used to allow for cross-category and cross-case comparison. Half of the women described having a clear choice in their decision to test. Others were less clear about their choice. Some women felt they had no choice in testing for HIV. None of the women stated that they were tested without having signed a consent form. We found that half of the women's narratives illustrated direct and indirect ways in which providers coerced them into taking an HIV test while receiving antenatal care. As the new guidance on HIV testing is implemented in different settings, it is critical to monitor women's testing experiences to ensure that a woman's right to make an informed, voluntary choice is not violated. Furthermore, models of testing that allow us to meet broader public health goals while simultaneously respecting women's autonomy are needed.

Antenatal care can act as an excellent tool to improve access to HIV counseling and testing services. This paper investigates an issue that may weaken its potential, namely lack of male involvement. We explored married men's perceptions of HIV in pregnancy and male involvement in antenatal HIV testing and counseling in Southern Malawi through 11 focus group discussions and a cross-sectional survey (n=388). The main findings were that men were largely unaware of available antenatal HIV testing and counseling services, and perceived it overall problematic to attend female-oriented health care. Most men supported provision of antenatal HIV testing. They perceived husbands to participate in the process indirectly through spousal communication, being faithful during pregnancy, and supporting the wife if found HIV-positive. Involvement of husbands was compromised by men's reluctance to learn their HIV status and the threat that HIV poses on marriage. Men stressed the importance of prior spousal agreement of antenatal HIV testing and considered HIV testing without their consent a valid reason for divorce. We suggest that male involvement in antenatal HIV testing requires refocusing of information and health services to include men. To avoid negative social outcomes for women, comprehensive and early involvement of men is essential.

This paper explores HIV-infected women's experiences of considering and using recommended interventions during pregnancy and postpartum to reduce mother-to-child transmission of HIV. Data were collected from 45 HIV-infected women aged 18-44 years living in Melbourne, Australia. A semi-structured interview was used to collect qualitative information on women's reproductive experience and intentions. The 15 women who had their children after their HIV diagnosis engaged in significant work including surveillance and safety work to minimise stigma and infection, information work to inform decisions and actions, accounting work to calculate risk and benefit, hope and worry work concerning a child's infection status and impact of interventions, work to redefine an acceptable maternal identity, work to prepare an alternative story to counter the disclosure effect of the intervention and emotional work to reconcile guilt when considering these interventions. This study provides a framework to help clinicians understand the real and on-going "work" that women engage in when they are considering interventions recommended by their physicians to reduce transmission of HIV. Even in circumstances where access to and acceptance of interventions are high, women continue to engage in this work even after they have a made a decision about a particular intervention.

HIV-positive pregnant women often do not disclose their serostatus to their partners, family and friends, creating potential barriers to preventing sexual transmission to partners and mother-to-child transmission through breastfeeding. This research explores recently diagnosed HIV-positive pregnant women's reasons for disclosure and non-disclosure of serostatus to various members of their social networks, as well as the consequences of their disclosure. Data were collected through open-ended questions as part of a semi-structured interview with 293 recently diagnosed HIV-positive pregnant women recruited from antenatal clinics in two townships in Tshwane, South Africa. A content analysis of responses showed that women weighed fear of abandonment and discrimination against their desire to raise risk awareness and their need for support. Partners most often responded to disclosure with disbelief and shock, whereas parents frequently exhibited emotional distress, but were still supportive, as were other relatives and friends. The women subsequently experienced low levels of adverse consequences after disclosure. The results can assist healthcare providers in understanding the complexity of pregnant women's decisions to disclose to various members of their social networks and emphasize the need for continued counselling and support.

Among women with HIV infection, pregnancy is a time when maintenance of maternal health and reduction of vertical HIV transmission are primary concerns. Few studies have examined adherence to Antiretroviral Treatment (ART) during pregnancy and in the postpartum period when the demands of childcare may significantly interfere with women's self-care behaviors. This study examined ART use and adherence in HIV-infected pregnant and postpartum women participating in the Women and Infants Transmission Study (WITS-IV) in the US. Adherence was assessed through a self-report interview during the third trimester of pregnancy and six-month postpartum. Data were also collected on demographics, biomedical markers and health related symptoms. During the third trimester visit, 77% (309/399) of women completed the self-report adherence measure; 61% (188/309) reported complete adherence. Factors associated with non-adherence included advanced HIV disease status, higher HIV-RNA viral load, more health-related symptoms and alcohol and tobacco use. At six-month postpartum, 55% (220/399) completed the measure; 44% (97/220) of these women reported complete adherence. Factors associated with non-adherence during the postpartum period were ethnicity, more health-related symptoms and WITS clinical site. Results of multivariate analyses using Generalized Estimated Equation analyses across the two visits revealed that more health-related symptoms, higher HIV-RNA viral load, increased alcohol use and clinical site were independently associated with ART non-adherence. These analyses indicate that medication adherence is more likely during pregnancy than postpartum in HIV-infected women, perhaps provoked by motivation to reduce vertical transmission and/or intensive antepartum surveillance. Further investigation is warranted to clarify factors implicated in women's decision-making process regarding ART medication adherence.

Although policies and programs exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved and may be deteriorating in some countries. Part of the explanation may be the adverse effects of HIV/AIDS on maternity care. We conducted a study in Kisumu, Kenya to explore how fears related to HIV/AIDS affect women's uptake and health workers' provision of labor and delivery services. In-depth qualitative interviews with 17 maternity workers, 14 pregnant or postpartum women, four male partners and two traditional birth attendants; as well as structured observations of 22 births; were conducted at four health facilities. Participants reported that fears of HIV testing; fears of involuntary disclosure of HIV status to others, including spouses; and HIV/AIDS stigma are among the reasons that women avoid delivering in health facilities. Maternity workers now have to take into account the HIV status of the women they serve (as well as their own fears of becoming infected and stigmatized) but do not seem to be adequately prepared to handle issues related to consent, confidentiality and disclosure. Importantly, it appeared that women of unknown HIV status during labor and delivery were likely to be targets of stigma and discriminatory practices and that these women were not receiving needed counseling services. The findings suggest that increasing infection control precautions will not be enough to address the challenges faced by maternity care providers in caring for women in high-HIV-prevalence settings. Maternity workers need enhanced culturally sensitive training regarding consent, confidentiality and disclosure. Furthermore, this study points to the necessity of paying more attention to the care of women of unknown HIV-serostatus during labor and delivery. Such interventions may improve the quality of maternity care, increase utilization and contribute to overall improvements in maternal health, while also enhancing prevention of mother-to-child-transmission and HIV care.

The objective of this study is to assess the understanding of routine offer of HIV testing among women using antenatal care (ANC) services in a rural African district. A descriptive cross-sectional survey was conducted in Murewa district, Zimbabwe, among women consecutively enrolled during their first ANC visit in 10 health centres offering prevention of mother-to-child transmission (PMTCT) of HIV services including routine offer of HIV testing. Ninety-three (64%) of the 146 respondents had received some form of education on the importance of HIV testing before visiting the health centre on the day of their interview. Almost all respondents (n=139; 95%) felt that the information provided during the group education was sufficient to make a decision on whether or not they should have an HIV test. HIV testing uptake was high with 136 (93%) women being tested for HIV on the day of the interview. Of these, 128 (94%) were aware that they had been tested for HIV when interviewed before the time of receiving results. Fifty percent (n=67) of the women who accepted HIV testing directly after group education as part of their routine ANC blood tests were not aware, however, of the possibility of opting for individual pre-test counseling. The study found that in Zimbabwe, implementation of routine offer of HIV testing allowed women using ANC services to make an informed conscious decision to undertake an HIV test as part of the PMTCT package of services. There is a need to emphasize the availability of further individual pre-test counseling if necessary since a selected subgroup of women may still benefit from it.

HIV testing is an essential component of PMTCT. It can be offered to pregnant women through different testing models, ranging from voluntary counseling and testing (VCT) to routine and mandatory testing. This study was conducted in Hanoi, Vietnam, where HIV-prevalence is low among the general population, but high among young, urban, sexually active, male intravenous drug users. Women who want to deliver in a state hospital are routinely tested for HIV in the absence of well-defined opt-out procedures. In-depth interviews with a convenience sample of 38 seropositive pregnant women and mothers and 53 health workers explored the acceptability of routine testing. Patients and healthcare workers appeared to accept routine 'blood' tests (including HIV tests) because they feel uncomfortable discussing issues specific to HIV/AIDS. To avoid having to inform women directly about their HIV status, health workers at routine testing sites rely on the official notification system, shifting the responsibility from the hospitals to district and commune health staff. The notification system in Hanoi informs these local officials about the HIV status of people living in their catchment area without patients' consent. Our study shows that this non-confidential process can have serious social, economic and health consequences for the HIV-positive women and their children.

Our objective was to assess the mental health status of pregnant women who are HIV-positive, compared with other groups of pregnant women. We evaluated pregnant HIV-positive women attending the Medecins Sans Frontiers (MSF) HIV clinic in Malanje, Angola (N = 23). The control group consisted of pregnant women coming for antenatal clinic consultations who were not known to be HIV-positive (N=134). To assess mental health, the 12-item General Health Questionnaire (GHQ-12) was used. A score of three or greater was considered to indicate significant emotional distress. We also examined determinants of emotional distress in logistic multivariate regression models. We found that the mean score on the GHQ-12 for the HIV-positive group was more than twice the mean score of the controls, indicating poorer mental health in the HIV-positive group. Two-thirds of HIV-positive women had significant emotional distress, more than twice that in the control group. As well as HIV status, marital status was a strong independent predictor of mental health status, with married women experiencing less emotional distress. Thus, in our sample, pregnant women who were HIV-positive had a much poorer mental health status than the controls. Strategies to improve the mental health of HIV-positive mothers must be implemented and evaluated; efforts to decrease the levels of stigma and discrimination in this population are of key importance.

While the ability to lead a healthy sexual life and to choose whether and when to have children are well-established features of reproductive health and human rights, issues surrounding sexual activity and childbearing among HIV-infected women and men have received little attention in sub-Saharan Africa. We conducted a semi-structured, cross-sectional survey at 26 primary health care clinics in South Africa to investigate community attitudes towards sexual activity and reproduction by HIV-infected individuals. Of the 843 women interviewed, slightly less than half (43%, n = 361) thought that people living with HIV/AIDS should remain sexually active if they choose, while 13% (n = 113) said they thought that people living with HIV/AIDS should have children if they wished to do so. In multivariate analysis, negative attitudes towards both sexuality and childbearing were persistently associated with not knowing someone infected with HIV (p = 0.001 and 0.043, respectively). These findings suggest that the sexual and reproductive health rights of HIV-infected women and men may be an important target as part of efforts to reduce HIV/AIDS-related stigma. Health policies and services are required to reinforce the reproductive rights of HIV-infected individuals in South Africa and other countries in sub-Saharan Africa where HIV is most prevalent.

To study the effect of HIV infection on quality of life (QOL) during pregnancy and puerperium, QOL was measured in a cohort study at St. Francis Hospital Nsambya, Kampala, Uganda. Dartmouth COOP charts were administered to 132 HIV-positive and 399 HIV-negative women at 36 weeks of pregnancy and six weeks post-partum. Responses were coded from 0 = best health-status to 4 = worst health-status and scores of 3-4 defined as poor. Odds ratios (OR) (95% confidence intervals(CI)) for poor scores were calculated and independent predictors of poor QOL examined using logistic regression. In pregnancy, HIV-positive women were more likely to have poor scores in feelings: OR = 3.2(1.9-5.3), daily activities: OR = 2.8(1.4-5.5), pain: OR = 2.1(1.3-3.5), overall health: OR = 1.7(1.1-2.7) and QOL: OR = 7.2(3.6-14.7), all p= 0.2). HIV infection was independently associated with poor QOL: OR = 8.5(3.8-19). Findings in puerperium were similar to those in pregnancy except more HIV-positive women had poor scores in social activities: OR = 2.5(1.4-4.7) and change in health: OR = 5.4(2-14.5) and infant death also predicted poor QOL: OR = 6.7(2.4-18.5). The findings reflect HIV's adverse impact on maternal QOL and the need for interventions to alleviate this infection's social and emotional effects.

The aim of this study was to analyze the dynamics of ideology, power and language in the dominant discourses about childbearing by couples with HIV that were expressed by AIDS care professionals in Taiwan. Critical discourse analysis of the interview texts with 11 AIDS care professionals identified three prevailing discourses on childbearing by couples with HIV/AIDS: pro-children, conditional pro-choice and pro-rights. The pro-children and conditional pro-choice were the predominant discourses. The two discourses both medicalized childbearing among couples with HIV/AIDS by identifying medical authorities as the proper persons to decide which reproductive choices people with HIV/AIDS should make under what conditions. Even though the pro-rights discourse embodied an ideology of individualism, empowerment and autonomy, it was weak and relatively rare in the other two discourses.

This study reports the results of a cross-sectional questionnaire survey undertaken in the Kassena-Nankana district of Ghana to assess the perception and attitude of 270 antenatal clinic attendants towards voluntary counseling and HIV testing. It was found that although 92.6% (95% CI 88.8-95.4) of respondents indicated a willingness to get tested, only 51% (95% CI 45.0-57.2) considered HIV testing for pregnant women to be useful. Most (93.6%) indicated they would like their husbands (partners) to know the result of the test and 52.2% indicated that their husbands would be willing to accompany them to antenatal clinic (ANC) at least once during the pregnancy. The perception of the usefulness of HIV testing (OR = 8.5, 95% CI 1.8-40.0), the willingness to disclose test result to the husband (OR = 13.3, 95% CI 4.0-44.5) and perceived willingness of husband to accompany wife to antenatal clinic (OR = 5.2, 95% CI 1.4-19.8) were found to be independent predictors of a woman's willingness to get tested. The willingness to disclose test result to husband (OR 3.2, 95% CI 1.1-10.5) and knowledge of at least one mode of MTCT HIV transmission (OR = 2.1, 95% CI 1.2-3.6) were found to be independent predictors of a woman's perception that getting tested was useful. The results suggest that for pregnant women in this district, the willingness to get tested for HIV does not equate with the perception of the test's usefulness, and that spouses are likely to exert strong influence on the attitude of pregnant women towards VCT. Couple counseling facilitated through couple-friendly ANC services should be explored as strategy for the intended VCT program in this district.

The diagnosis of HIV in a pregnant women or pregnancy in an HIV-positive woman can be associated with an affective disorder, caring for which can present a major challenge for physicians and health care workers. The associated somatic symptoms can cause serious morbidity. This study aims to explore the mental health of pregnant HIV-infected women. The study took place at the University Teaching Hospital in Lusaka, Zambia and at satellite clinics. Study participants were either pregnant women who were diagnosed with HIV during the course of their pregnancy, or women who knew their HIV-positive status prior to becoming pregnant. A questionnaire was used to assess the psychological state of the women. The majority of women (85%) showed major depressive episodes and had significant suicidal thoughts. About 60% of the women whose HIV was diagnosed during their pregnancy showed signs of somatic illness. Those who knew their HIV status before becoming pregnant did not show severe depressive episodes, but showed anxiety about the HIV status of their babies. This suggests that women who discover their HIV status during the course of their pregnancy are more liable to develop major depressive illness and somatic disorders. Physicians dealing with these women need to be cognisant of the strain HIV can add to pregnancy and of the psychological and psychiatric support they may require.

This descriptive study sought to identify factors that influence HIV-infected women's intent to get pregnant. Interviews were conducted with a convenience sample of n = 322 HIV-infected women at risk for pregnancy. Participants were predominantly African-American (84.4%), single (57.9%), and ranged in age from 17 to 48 years. Forty per cent (n = 128) of the women had been pregnant since becoming HIV-positive. Potential factors influencing intent to get pregnant that were examined included demographic characteristics, HIV-related factors and personal beliefs and attitudes. In simple logistic regression models, younger age, increased motivation for child bearing, decreased perceived threat of HIV, decreased HIV symptomatology, higher traditional gender role orientation, and greater avoidance coping were all associated with greater intent to get pregnant. Following a model selection procedure, motivation for child bearing (OR = 16.05, 95% CI 7.95, 30.41) and traditional sex roles (OR = 4.49, 95% CI 1.44, 13.55) were significantly associated with greater intent to get pregnant. Traditional gender role orientation and motivation for childbearing are significant factors in predicting intent to get pregnant among HIV-infected women. These factors, as well as other non HIV-related factors, need to be routinely assessed by health care providers in developing plans of care for HIV-infected women.

Unlabelled: This paper describes the results of a study exploring the attitudes of women attending maternity clinics to voluntary counselling and testing during pregnancy in rural areas in south-west Uganda. It was a qualitative study using focus group discussions (FGDs). Twenty-four FGDs were carried out with 208 women attending maternity clinics in three sites in rural south-west Uganda. The FGDs were all recorded and transcribed, and analysed using standard computer-based qualitative techniques. Almost all women were willing in principle to take an HIV test in the event of pregnancy, and to reveal their HIV status to maternity staff. They were anxious, however, about confidentiality, and there was a widespread fear that maternity staff might refuse to assist them when the time came to deliver if their status were known. This applied more to traditional birth attendants than to biomedical health staff. There were also rumours about medical staff intentionally killing HIV-positive patients in order to stem the spread of the epidemic. Women were concerned that if their husbands found out they were HIV-positive they would be blamed and separation or domestic violence might result., In Conclusion: although VCT during pregnancy is acceptable in principle, much will need to be done to ensure confidentiality and allay women's fears of stigmatisation and discrimination during delivery. Community sensitisation will be necessary and male partners will have to be involved if interventions are to be acceptable.

The mood of nihilism that affected HIV is now changing. The availability of new therapies allows for cautious optimism--especially in relation to mother-to-child transmission of HIV and preventative interventions. This has prompted a widespread policy shift towards HIV testing in pregnancy. In this context, informed consent is an ethical issue which needs to be addressed. This study reports on two sets of data exploring consent policy and practices in UK antenatal clinics. The first is derived from an audit of obstetric clinics in the UK and Eire (n = 288), with a 91% response rate. The second provided the views on consent and testing of a cohort of pregnant women attending four London antenatal clinics (n = 697). It was found that written consent was more likely to be obtained in units with a universal HIV testing offer (p = 0.0005); 77.8% of women believed consent would be requested, but 17.7% believed they could not refuse an HIV test. Their views were contrasted with those held about other antenatal screening tests. The data show that the generally haphazard method of giving information and obtaining consent in antenatal HIV provision is probably counterproductive in terms of test uptake and the ultimate goal of minimizing maternal-fetal HIV transmission.

This study examined the immediate effects of exposure to a patient education brochure concerning the risks and benefits of zidovudine (ZDV) therapy during pregnancy to reduce perinatal HIV transmission (protocol ACTG 076) on related knowledge, behavioural intentions and attitudes of women with and at-risk for HIV-infection. Self-reports were collected from 653 women of childbearing age from community family planning clinics and hospital-based HIV centres in 19 sites from nine US cities between May and November 1995. The intervention was a nine-page patient education brochure in Spanish, Creole and English versions, evently presenting the pros and cons of ZDV therapy to reduce perinatal HIV-transmission. Brochure exposure increased knowledge (p < 0.001) for all but one scale concerning ZDV resistance and increased the likelihood of women reporting intentions to take ZDV during pregnancy (p < 0.001) and to believe ZDV reduced transmission (p < 0.001). Brochure exposure had differential effects for some subpopulations. Intentions to have or terminate current or future pregnancies, knowledge about ZDV and attitudes toward ZDV varied mostly by ethnicity/race, language preference and HIV status. Pregnancy status, age, education and having an HIV-positive child had less impact on the brochure's effect, while income had no impact.

In a Bangkok antenatal clinic, we interviewed 102 HIV-infected pregnant women and their husbands, 30% of whom were HIV-negative. We evaluated these data by matched and unmatched analysis, compared men and women in stable couple relationships on a number of sociodemographic and risk factor indicators and investigated further whether there were any differences in sociodemographic or risk factor profiles between HIV-serodiscordant couples and seroconcordant couples. When compared to wives, more of the husbands were working (p = 0.001), earning more money (p = 0.001), had had more than two sex partners (p = 0.001) and had had syphilis (p = 0.001). Serodiscordant couples did not differ greatly from seroconcordant couples except that women married to HIV-negative men were more likely to have been divorced or separated than their husbands which was not the case for women married to HIV-positive men (p = 0.02). There was poor agreement between husband and wife reports of husband risk behaviour and this did not differ between concordant and discordant couples. These findings suggest that assessment of risk and counselling of Thai women is incomplete without information on the HIV status and risk behaviour of her partner. Prevention strategies to decrease heterosexual transmission among couples need to target both the man and the woman.

The object of this study supported by the French Agency for AIDs Research (ANRS) was to assess knowledge and attitudes of pregnant women towards HIV infection and testing, and to compare them according to the outcome of the pregnancy (elective abortion vs delivery). Between March 22 and April 26, 1992, all women ending their pregnancy and attending one of the 72 medical centres located in South-Eastern France were asked to complete an anonymous questionnaire (n = 4303). 3,854 (89.6%) responded: 2,825 women at delivery (WD) and 764 who chose an elective abortion (WA). 61.7% of WD and 24.1% of WA declared having been tested for HIV during pregnancy (p < 0.001). Among women who reported not having been HIV tested, very few did so because they refused the test (1.7% among WD and 1.4% among WA-NS). Prior HIV testing was less frequent among WA than among WD (45.8% vs 58.8%--p < 0.001). 2.8% of women tested during prenatal care and 20% in the context of abortion did not know the result of their test (p < 0.001). Knowledge about HIV transmission declared by WD did not differ significantly from that declared by WA. However, risky behaviours were more frequent among WA than among WD (38.9% vs 17.7%--p < 0.001). This research shows that French screening HIV policy in the context of pregnancy remains mainly motivated by foetal concerns. Although women who abort voluntarily report risky behaviours more frequently, the opportunity of information and counselling towards them is relatively neglected in comparison with women who deliver.

The condom is widely recommended as the principal method for preventing HIV transmission, but such advice obviously does not apply to women who are seeking to become pregnant. In this sense, 'safer sex' is incompatible with reproduction. Existing research into HIV transmission has examined the choices made by those wishing to conceive within a sexual relationship; such research shows that HIV is not a highly significant factor in their decision-making processes. This study aims to extend the debate by exploring the decision-making processes of women seeking to become pregnant with donated sperm. In particular, we focus on women outside the fertility clinic system who do not have access to sperm screened for HIV to see whether HIV is a significant factor in these women's decisions. The study involved in-depth interviews with 20 women (14 lesbians, one bisexual and five heterosexuals) recruited through informal networking and snowball sampling. HIV was a salient concern for our sample, largely because of their contacts with gay men, but nonetheless most of these women took some risks. On the one hand, the conscious deliberations necessary to conceive through self-insemination facilitated risk reduction, as did factors such as 'stranger-danger'. On the other hand, factors such as the scarcity of suitable sperm donors and the women's own feelings of gratitude and loyalty to their donors mitigated against their requesting that their donor take an HIV test. This study highlights the need to provide information for women seeking self-insemination, and to remove restrictions on access to fertility clinics, in order to reduce their risk of HIV infection and subsequent vertical transmission.

An Indian Sikh family affected with both HIV and haemophilia is described. The use of interpreters; the regular follow-up in the Concorde trial; family therapy and help with practical problems have been approaches used to help the family despite language and cultural differences.

In order to identify which factors predict a parturient womans intention to take up voluntary HIV testing in the antenatal clinic, 318 women were surveyed by anonymous self-completion questionnaire. The strongest predictors of intention to be tested were the perceived benefit of the test to the woman herself, her partner, and the midwife, perceived risk of HIV infection, younger age and being single and having a poor knowledge of the sexual routes of HIV transmission. Health education strategies should therefore concentrate on: (a) increasing the parturient woman's knowledge of HIV transmission which will increase accuracy of perception of risk; and (b) stressing the potential benefits of HIV testing to all antenatal attenders, particularly to those who are older and in long term relationships.

The paper presents the results of a survey about risk perception, knowledge, and attitudes towards HIV infection among 397 pregnant women in France. The survey was carried out between December 1987 and March 1988 in two Paris-region maternity hospitals where HIV testing is routinely proposed during the first prenatal visit. Uptake of HIV prenatal testing has been rapid in France: before coming to the maternity hospitals, 26.5% of women had already been tested. Social acceptability of testing is high, 68.8% of the sample even supporting mandatory prenatal HIV screening. Such acceptability appears to be based less on an in-depth knowledge about the risks of transmission from mother-to-fetus than on the general French context of free-of-charge mandatory prenatal care and on the potentially reassuring effect of a true negative test. Consensus about abortion for HIV-infected pregnant women is strong (80.1%) and is not influenced by religious beliefs, in contrast to attitudes toward abortion in the case of fetal handicaps. This social environment creates special difficulties for the management of the complex dilemmas regarding pregnancy and childbearing for HIV-infected women.

This study looked at 12 midwives in the Riverside Health Authority who counselled parturient women about having the HIV antibody test. Results showed that the uptake rate of the test varied considerably across midwives (82% to 3%). Uptake rate varied, to some extent, by ethnic group of the midwife; Afro-Caribbeans having 36% uptake, others 11%. However, the wide variation within these groups suggests that ethnicity alone does not explain the difference in uptake rate. Factors which could be associated with uptake rate are the individual characteristics of both the midwife and of the antenatal clinic attender, such as age, ethnicity, knowledge of and attitudes to HIV and antibody testing, as well as the counselling approach of the individual midwife.