Date Published: February 13, 2017
Publisher: Springer US
Author(s): Hazar Khidir, Christina Psaros, Letitia Greener, Kasey O’Neil, Mxolisi Mathenjwa, F. N. Mosery, Lizzie Moore, Abigail Harrison, David R. Bangsberg, Jennifer A. Smit, Steven A. Safren, Lynn T. Matthews.
Within sexual partnerships, men make many decisions about sexual behavior, reproductive goals, and HIV prevention. There are increasing calls to involve men in reproductive health and HIV prevention. This paper describes the process of creating and evaluating the acceptability of a safer conception intervention for men living with HIV who want to have children with partners at risk for acquiring HIV in KwaZulu-Natal, South Africa. Based on formative work conducted with men and women living with HIV, their partners, and providers, we developed an intervention based on principles of cognitive-behavioral therapy to support men in the adoption of HIV risk-reduction behaviors such as HIV-serostatus disclosure and uptake of and adherence to antiretroviral therapy. Structured group discussions were used to explore intervention acceptability and feasibility. Our work demonstrates that men are eager for reproductive health services, but face unique barriers to accessing them.
Many people living with HIV (PLWH) want to have children . South Africa has the largest population of PLWH in the world, and the majority are of reproductive age . Moreover, HIV-serodiscordance amongst stable South African couples is highly prevalent . Given that over 60% of new HIV infections in sub-Saharan Africa are estimated to occur in stable, serodiscordant sexual partnerships  and serodiscordant couples risk HIV transmission to achieve pregnancy [5, 6], intended conception likely represents a significant contributor to incident HIV infections . However, HIV prevention counseling for PLWH and their partners rarely addresses their reproductive desires [8, 9].
We experienced challenges in recruiting and retaining men for our structured group discussions. Many men were ineligible because they had known their HIV serostatus for fewer than 6 months or reported an HIV-infected partner; moreover, six of the men who met eligibility criteria could not attend the group discussions due to work scheduling conflicts (Fig. 4). Although group discussions did not include the number of participants that constitute a typical focus group discussion, we conducted structured group discussions with the participants who were available, employing a focus group discussion format.Fig. 4Structured group discussions recruitment flowchart
Across the three group discussions (GD), participants described interest in receiving information on strategies they could use to conceive and excitement at the idea of a safer conception resource.P3: “That [how to have children without transmitting HIV to partners] is exactly what we want to know. As to what can be the protection for the baby from being infected, as well as how the female can be protected.” –GD1
Participants described a number of challenges to participating in the proposed intervention. Several participants noted that many men living with HIV could benefit from the intervention but would not take up the resource because they are apprehensive to engage in HIV care.P2: “…there are many men nowadays who want to [have children] but they do not speak out, that is a challenge for men. Because, my sister, this is very helpful there are many men who wish for this. I really do not know how we can do that so that this gets to have a wide range because there are so many who want to have babies but are afraid to speak out.” –GD1P3: “Even [at the clinic], people who you find mostly are women. There are fewer men who come here, you do not find them because they are scared.” –GD1
Participants also reported that men don’t have enough information about HIV and what care is available and called for increasing community awareness about safer conception strategies. Participants cited difficulties scheduling sessions around employment responsibilities as a practical challenge to the proposed multi-session intervention. This was reflected in the challenges we encountered in scheduling focus group discussions around the men’s varied work schedules.
Participants who had disclosed their status to their partner reported that it would be feasible for men to bring their partners to counseling sessions, citing that it would provide opportunities to explain their intentions, to initiate new reproductive strategies, and recruit her to participate in safer conception plans. However, participants who had not yet disclosed felt that it would be very challenging to engage partners.P10: “I would be able to bring her because our life is based on a condom. So if we have to stop using a condom without having explained to her or if she finds out from me she might not trust this strategy. She might think I want to put her in trouble, but if she comes with me and get the same information and counseling and when we do what we will be doing in whatever method I think she might also feel comfortable and perhaps that baby could be a success because we will both be focused on one thing.” –GD3P4: “It is very difficult because she does not know that I am already infected.” –GD2
Development of the Men’s Safer Conception Intervention was a 5-year, iterative process that revealed key insights into the reproductive health demands of MLWH. Important insights gained from our mixed-methods studies with HIV-infected individuals in confirmed- and potentially-serodiscordant relationships include that PLWH risk sexual HIV transmission to meet fertility goals, men often dominate decisions around use of risk-reduction strategies, and that healthcare providers rarely share safer conception opportunities with men. These findings revealed the need for programs that engage men in reproductive health. Our findings that MLWH expressed eagerness for more reproductive health programming and modify their HIV-risk behavior to protect their offspring suggest that men are willing to participate in a safer conception intervention and provided an opportunity to motivate men to modify HIV risk behaviors. We developed an educational CBT intervention consisting of three core sessions and two follow up sessions. The intervention provides comprehensive education on safer conception strategies, encourages men to adopt an explicit plan to implement safer conception strategies, and uses behavioral skills training to support men as they begin to implement their Healthy Baby Plan. After developing our intervention content, we used a multiphase participatory research approach to refine our intervention . The intervention was well-received by structured group discussion participants from our target population. MLWH expressed excitement toward the prospect of a safer conception resource and willingness to attend clinic over multiple sessions for the purpose of accessing reproductive health resources. This finding questions historical assumptions that this population is not interested in seeking these resources [18, 53, 54].