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Uptake of pre-exposure prophylaxis (PrEP) fell short of targets for Sub-Saharan Africa's initial rollout, revealing the need for more effective promotion strategies. In Uganda, we explored potential benefits and challenges of integrating safer conception messaging to promote PrEP among serodiscordant couples. In-depth interviews were conducted with clients and personnel at three clinics and analyzed thematically. Participants (n = 58) valued PrEP as a safer conception method (SCM) but described lack of integration of safer conception and PrEP services as well as inconsistent practices in prescribing PrEP to couples pursuing conception. Participants reported that the wider population remains largely unaware of PrEP and SCM or harbors misconceptions that PrEP is primarily for highly stigmatized groups like sex workers. Participants further described how heterosexual couples can still be reluctant to test for HIV, unaware of tools like PrEP and SCM that would allow them to continue their relationship and/or pursuit of childbearing. Overall, findings suggest that integrating PrEP and SCM in messaging and services targeting serodiscordant couples holds untapped benefits throughout the HIV prevention cascade. [ABSTRACT FROM AUTHOR]

In Uganda, 60% of HIV-affected couples are serodiscordant, many of whom want children. There is a need to assess their reproductive intentions and provide appropriate services that limit transmission risks while meeting reproductive goals. Our Choice intervention engaged male and female HIV-infected clients and their partners in safer conception counseling (SCC) or family planning based on their childbearing decision. We report findings of provider experiences and recommendations for engaging couples in SCC. The intervention was implemented in four clinics offering either SCC1, an intensive training and supervision arm, or SCC2, utilizing the Ministry of Health's standard approach. Qualitative interviews were conducted at 12 (N = 23) and 24 months (N = 25) after initiation of the intervention. Many partners attended at least some SCC sessions, although engaging male partners was more challenging. Providers reported partner involvement improved understanding and facilitated successful implementation of SCM, whereas confusion and challenges were common when the client participated alone. Providers shared successful strategies for engaging male partners. [ABSTRACT FROM AUTHOR]

Background: Safer conception counseling (SCC) to promote the use of safer conception methods (SCM) is not yet part of routine family planning or HIV care. Guidelines for the use of SCM have been published, but to date there are no published controlled evaluations of SCC. Furthermore, it is unknown whether standard methods commonly used in resource constrained settings to integrate new services would be sufficient, or if enhanced training and supervision would result in a more efficacious approach to implementing SCC.Methods: In a hybrid, cluster randomized controlled trial, six HIV clinics were randomly assigned to implement the SCC intervention Our Choice using either a high (SCC1) or low intensity (SCC2) approach (differentiated by amount of training and supervision), or existing family planning services (usual care). Three hundred eighty-nine HIV clients considering childbearing with an HIV-negative partner enrolled. The primary outcome was self-reported use of appropriate reproductive method (SCM if trying to conceive; modern contraceptives if not) over 12 months or until pregnancy.Results: The combined intervention groups used appropriate reproductive methods more than usual care [20.8% vs. 6.9%; adjusted OR (95% CI)=10.63 (2.79, 40.49)], and SCC1 reported a higher rate than SCC2 [27.1% vs. 14.6%; OR (95% CI)=4.50 (1.44, 14.01)]. Among those trying to conceive, the intervention arms reported greater accurate use of SCM compared to usual care [24.1% vs. 0%; OR (95% CI)=91.84 (4.94, 1709.0)], and SCC1 performed better than SCC2 [34.6% vs. 11.5%; OR (95% CI)=6.43 (1.90, 21.73)]. The arms did not vary on modern contraception use among those not trying to conceive. A cost of $631 per person was estimated to obtain accurate use of SCM in SCC1, compared to $1014 in SCC2.Conclusions: More intensive provider training and more frequent supervision leads to greater adoption of complex SCM behaviors and is more cost-effective than the standard low intensity implementation approach.Trial Registration: Clinicaltrials.gov, NCT03167879 ; date registered May 23, 2017. [ABSTRACT FROM AUTHOR]

Context: Among people living with HIV in Uganda, desires to have a child and unplanned pregnancies are both common, while utilization of safer conception methods (SCM) and modern contraceptives are low.Methods: Three hundred eighty-nine HIV clients who reported considering childbearing with their uninfected partner enrolled in a safer conception counseling intervention trial in Uganda. Multiple regression analysis and baseline data were used to examine correlates of reproductive intentions and behaviors, including use of safer conception methods and contraception.Results: Most (n = 313; 80.5%) reported that both they and their partner wanted to have a child now, which was associated with being married, in a longer relationship, not having a child with partner, greater SCM knowledge, lower internalized childbearing stigma, and higher perceived community stigma of childbearing. However, just 117 reported trying to conceive in the prior 6 months, which was associated with being female, not having a child with their partner, less decision-making control within the relationship, and greater perceived cultural acceptability of SCM. Among those who had tried to conceive in the past 6 months, 14 (11.9%) used SCM, which was associated with greater control in decision making. Of the 268 who were not trying to conceive, 69 (25.7%) were using a modern contraceptive, which was associated with being in a shorter relationship, less control over decision-making, more positive attitudes towards contraception and lower depression.Conclusion: Methods to promote reproductive goals are underused by HIV serodiscordant couples, and relationships characteristics and childbearing-related stigma appear to be most influential and thus targets for intervention.Trial Registration: Clinicaltrials.gov, NCT03167879 ; date registered May 23, 2017. [ABSTRACT FROM AUTHOR]

High rates of fertility desires, childbearing and serodiscordant partnerships among people living with HIV (PLHIV) in Uganda underscore the need to promote use of safer conception methods (SCM). Effective SCM exist but few PLHIV benefit from provider-led safer conception counseling (SCC) and comprehensive national SCC guidelines are still lacking. Providers’ self-efficacy, intentions and attitudes for SCC impact provision and should inform development of services, but there are no longitudinal studies that assess these important constructs. This study reports on changes in providers’ knowledge, attitudes, motivation and confidence to provide SCC among a 24-month observational cohort of Ugandan HIV providers. Compared to baseline, providers evidenced increased awareness of SCM, perceived greater value in providing SCC, saw all SCM but sperm washing as likely to be acceptable to clients, reported consistently high interest in and peer support for providing SCC, and perceived fewer barriers at the 24-month follow-up. Providers’ intentions for providing SCC stayed consistently high for all SCM except manual self-insemination which decreased at 24 months. Self-efficacy for providing SCC increased from baseline with the greatest improvement in providers’ confidence in advising serodiscordant couples where the man is HIV-infected. Providers consistently cite the lack of established guidelines, training, and their own reluctance to broach the issue with clients as significant barriers to providing SCC. Despite providers being more interested and open to providing SCC than ever, integration of SCC into standard HIV services has not happened. Concerted efforts are needed to address remaining barriers by establishing national SCC guidelines and implementing quality provider training. [ABSTRACT FROM AUTHOR]

Objective: We assessed the uptake of prevention of mother-to-child transmission (PMTCT) services in a cohort of HIV infected women in care at The AIDS Support Organization Jinja and Kampala in Uganda, who were trying to conceive, over a period of 24 months, to inform the strengthening of PMTCT service access for women in care. Results: Of the 299 women 127 (42.5%) reported at least one pregnancy within 24 months; 61 women (48.0%) delivered a live child. Of the 55 who had a live birth at the first pregnancy, 54 (98.2%) used antenatal care (ANC) starting at 15.5 weeks of gestation on average and 47/49 (95.9%) delivered at a health facility. Excluding miscarriages, 54 (98.2%) received ARVs during pregnancy. Of the 49 live births with post-delivery data, 37 (75.5%) tested the infant for HIV. 79 of the 127 (68.7%) spoke with providers about childbearing. Communication with providers was associated with ANC use (65.8% vs. 41.7%; p = .015). Despite the high rate of miscarriages and late ANC start, this study shows very high uptake of PMTCT services among PLHIV in care and their infants. Improved provider-client communication could enhance ANC attendance and PMTCT outcomes among HIV infected women in care. [ABSTRACT FROM AUTHOR]

The article examines the benefits and challenges of safer-conception counseling to help people with human immunodeficiency virus (HIV) at a clinic in Uganda reduce risk of transmission to partners and babies. Findings from the study showed that counseling can help HIV-infected individuals make informed choices about childbearing and safe contraception. It stresses the need to make controlled trials to check whether clients are using the methods correctly.

Introduction: Many HIV-affected couples living in sub-Saharan Africa desire to have children, but few quantitative studies have examined support for their childbearing needs. Our study explored client-provider communication about childbearing and safer conception among HIV clients in Uganda. Methods: 400 Ugandan HIV clients in committed relationships and with intentions to conceive were surveyed. Knowledge, attitudes and practices related to childbearing, and use of safer conception methods were assessed, including communication with providers about childbearing needs, the correlates of which were examined with bivariate statistics and logistic multivariate analysis. Results: 75% of the sample was female; 61% were on antiretroviral therapy; and 61% had HIV-negative or unknown status partners. Nearly all (98%) reported the desire to discuss childbearing intentions with their HIV provider; however, only 44% reported such discussions, the minority (28%) of which was initiated by the provider. Issues discussed with HIV providers included: HIV transmission risk to partner (30%), HIV transmission risk to child (30%), and how to prevent transmission to the child (27%); only 8% discussed safer conception methods. Regression analysis showed that those who had communicated with providers about childbearing were more likely to have been diagnosed with HIV for a longer period [OR (95% CI) = 1.09 (1.03, 1.15)], while greater internalized childbearing stigma was associated with lower odds of this communication [OR (95% CI) = 0.70 (0.49, 0.99)], after controlling for all bivariate correlates and basic demographics. Conclusions: Communication between HIV clients and providers about childbearing needs is poor and associated with stigma. Innovations to mitigate stigma among clients as well as training to improve health worker communication and skills related to safer conception counseling is needed. [ABSTRACT FROM AUTHOR]

We examined the prevalence and correlates of safer conception methods (SCM) use in HIV-affected couples with fertility intentions. A prospective cohort of 400 HIV clients in Uganda who had fertility intentions with their partner was surveyed every 6 months for 24 months. Logistic regression analysis was used to determine individual, relationship and provider level predictors of SCM use. Over one-third (35%) reported any use of timed unprotected intercourse (TUI) during the study; use of other SCM was rare. Baseline predictors of any TUI use included lower social support, greater perceived provider stigma of childbearing, greater SCM awareness, greater control over sexual decision making in the relationship, inconsistent condom use, and the belief that a desire for childbearing impedes condom use. These findings highlight the need for policy and provider training regarding integration of safer conception counselling into family planning and reproductive health services for people living with HIV. [ABSTRACT FROM AUTHOR]

In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges. [ABSTRACT FROM AUTHOR]

With data from 400 HIV clients with fertility intentions and 57 HIV providers in Uganda, we evaluated the psychometrics of new client and provider scales measuring constructs related to safer conception methods (SCM) and safer conception counselling (SCC). Several forms of validity (i.e., content, face, and construct validity) were examined using standard methods including exploratory and confirmatory factor analysis. Internal consistency was established using Cronbach's alpha correlation coefficient. The final scales consisted of measures of attitudes towards use of SCM and delivery of SCC, including measures of self-efficacy and motivation to use SCM, and perceived community stigma towards childbearing. Most client and all provider measures had moderate to high internal consistency (alphas 0.60-0.94), most had convergent validity (associations with other SCM or SCC-related measures), and client measures had divergent validity (poor associations with depression). These findings establish preliminary psychometric properties of these scales and should facilitate future studies of SCM and SCC. [ABSTRACT FROM AUTHOR]

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High rates of childbearing desires (59%) and serodiscordant partnerships (50%) among people living with HIV (PHLA) in Uganda highlight the need for safer conception counseling (SCC). Provider attitudes about counseling PLHA on the use of safer conception methods (SCM) have been explored in qualitative studies, but published quantitative investigations are scarce. Data from 57 Ugandan providers were collected to examine providers' attitudes about childbearing among PLHA and engagement in discussions about childbearing, as well as their knowledge, interest, self-efficacy, and intentions to provide SCC. Correlates of self-efficacy for the provision of SCC were explored to inform the development of training programs. Providers reported a general awareness of most SCM, especially timed unprotected intercourse (TUI); but just over half felt they knew enough to counsel clients in the future and all wanted more training. Childbearing was discussed with less than a third of reproductive aged patients and was mostly initiated by patients. Most providers saw value in providing SCC and believed that most aspects of SCM would be acceptable to their clients, but numerous barriers were endorsed. Self-efficacy was greatest among providers who had had more childbearing conversations, greater SCM awareness, perceived fewer barriers and greater intentions to counsel on TUI. Providers evidence fewer stigmatizing attitudes than in the past. However, those who endorsed more stigmatizing attitudes evidenced a trend for reporting lower self-efficacy for providing SCC. Training will need to simultaneously focus on increasing providers' SCC knowledge and skills while instilling a more realistic appraisal of the risks of assisting couples to employ SCM versus doing nothing. [ABSTRACT FROM AUTHOR]

We examined the correlates of use of safer conception methods (SCM) in a sample of 400 Ugandan HIV clients (75 % female; 61 % on antiretroviral therapy; 61 % with HIV-negative or unknown status partners) in heterosexual relationships with fertility intentions. SCM assessed included timed unprotected intercourse, manual self-insemination, sperm washing, and pre-exposure prophylaxis (PrEP). In the 6 months prior to baseline, 47 (12 %) reported using timed unprotected intercourse to reduce risk of HIV infection (or re-infection), none had used manual self-insemination or sperm washing, and two had used PrEP. In multiple regression analysis, correlates of use of timed unprotected intercourse included greater perceptions of partner's willingness to use SCM and providers' stigma of childbearing among people living with HIV, higher SCM knowledge, and desire for a child within the next 6 months. These findings highlight the need for policy and provider training regarding integration of couples' safer conception counselling into HIV care. [ABSTRACT FROM AUTHOR]

We conducted in-depth interviews with a variety of health care providers (n = 33) in Uganda to identify current services that could support and act as barriers to the provision of safer conception counseling (SCC). Consistent with their training and expertise, providers of all types reported provision of services for people living with a diagnosis of HIV or AIDS who desire a child. Important barriers, including a lack of service integration, poor communication between stakeholders, and the absence of policy guidelines, were identified. Drawing on these data, we propose a model of integrated care that includes both SCC services and prevention of unplanned pregnancies. [ABSTRACT FROM AUTHOR]

In this qualitative study, researchers assessed knowledge, acceptability, and feasibility of safer conception methods (SCM; timed unprotected intercourse [TUI], manual self-insemination, and sperm washing) among various health care providers (n = 33) and 48 HIV clients with recent or current childbearing intentions in Uganda. While several clients and providers had heard of SCM (especially TUI), few fully understood how to use the methods. All provider types expressed a desire to incorporate SCM into their practice; however, this will require training and counseling protocols, sensitization to overcome cultural norms that pose obstacles to these methods, and partner engagement (particularly by men) in safer conception counseling. [ABSTRACT FROM AUTHOR]

Objective: Data on early miscarriage incidence is limited due to various social and methodological barriers. We report on 24-month pregnancy outcomes of 299 female Ugandan HIV clients in committed relationships with an intention to conceive. Miscarriage data are reported as auxiliary findings to a larger study (5R01HD072633)., Results: 127 (42%) participants reported a pregnancy during the study; among the remaining 172, 82 indicated they stopped trying to conceive, and 16 dropped out prior to month 24. Of the 127 pregnancies, 55 (43%) resulted in live births, 67 (53%) in spontaneous miscarriage, 1 (< 1%) in stillbirth, 1 (< 1%) in abortion, and 3 (2%) in unknown outcomes. Three-quarters (75%) of miscarriages for which time until miscarriage was available were reported to occur in the first trimester (mean = 11.3 weeks gestation). The 67 participants who reported a miscarriage tended to be older (mean 33 vs. 30 years), but the significance of age did not persist after adjusting for multiple tests. We observed relatively low rates of pregnancy and high rates of miscarriage among this cohort of HIV-positive women wanting to conceive. Rigorously designed studies are needed to better understand the observed high rate of early miscarriage among HIV-infected women.

Background: About 40% of HIV-positive women in sub-Saharan Africa become pregnant post-diagnosis. Despite about half of their pregnancies being planned, safer conception methods (SCM) are underutilized among serodiscordant couples, partially due to the fact that safer conception counseling (SCC) has not been integrated into routine HIV family planning (FP) services., Methods: Our Choice is a comprehensive FP intervention that promotes unbiased childbearing consultations to ensure clients receive SCC or contraception services to achieve their desired reproductive goals. The intervention is theoretically grounded and has demonstrated preliminarily feasibility and acceptance through pilot testing. This three-arm cluster randomized controlled trial compares two implementation strategies for integrating Our Choice into routine FP services vs. usual care. Six sites in Uganda will be randomized to receive either (1) Our Choice intervention with enhanced training and supervision provided by study staff (SCC1), (2) Our Choice intervention implemented by the Ministry of Health's standard approach to disseminating new services (SCC2), or (3) existing FP services (usual care). Our Choice and usual care FP services will be implemented simultaneously over a 30-month period. Sixty clients in serodiscordant relationships who express childbearing desires will be enrolled by a study coordinator at each site (n = 360) and followed for 12 months or post-pregnancy (once, if applicable). Analysis will compare intervention arms (SCC1 and SCC2) to usual care and then to each other (SCC1 vs. SCC2) on the primary outcome of correct use of either SCM (if trying to conceive) or dual contraception (if pregnancy is not desired). Secondary outcomes (i.e., pregnancy, use of prevention of mother-to-child transmission services, condom use, and partner seroconversion) and cost-effectiveness will also be examined., Discussion: Findings will provide critical information about the success of implementation models of varying intensity for integrating SCC into FP, thereby informing policy and resource allocation within and beyond Uganda., Trial Registration: NCT03167879 ClinicalTrials.gov, Registered 30 May, 2017.