title: Lost opportunities to reduce periconception HIV transmission: safer conception counseling by South African providers addresses perinatal but not sexual HIV transmission.
abstract: BACKGROUND
  Safer conception strategies create opportunities for HIV-serodiscordant couples to realize fertility goals and minimize periconception HIV transmission. Patient-provider communication about fertility goals is the first step in safer conception counseling.
  
  
  METHODS
  We explored provider practices of assessing fertility intentions among HIV-infected men and women, attitudes toward people living with HIV (PLWH) having children, and knowledge and provision of safer conception advice. We conducted in-depth interviews (9 counselors, 15 nurses, 5 doctors) and focus group discussions (6 counselors, 7 professional nurses) in eThekwini District, South Africa. Data were translated, transcribed, and analyzed using content analysis with NVivo10 software.
  
  
  RESULTS
  Among 42 participants, median age was 41 (range, 28-60) years, 93% (39) were women, and median years worked in the clinic was 7 (range, 1-27). Some providers assessed women's, not men's, plans for having children at antiretroviral therapy initiation, to avoid fetal exposure to efavirenz. When conducted, reproductive counseling included CD4 cell count and HIV viral load assessment, advising mutual HIV status disclosure, and referral to another provider. Barriers to safer conception counseling included provider assumptions of HIV seroconcordance, low knowledge of safer conception strategies, personal feelings toward PLWH having children, and challenges to tailoring safer sex messages.
  
  
  CONCLUSIONS
  Providers need information about HIV serodiscordance and safer conception strategies to move beyond discussing only perinatal transmission and maternal health for PLWH who choose to conceive. Safer conception counseling may be more feasible if the message is distilled to delaying conception attempts until the infected partner is on antiretroviral therapy. Designated and motivated nurse providers may be required to provide comprehensive safer conception counseling.
authors.affiliation: *Center for Global Health and Division of Infectious Disease, Massachusetts General Hospital, Boston, MA; †MatCH Research (Maternal, Adolescent and Child Health Research), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa; ‡Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada; §Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA; ‖Harvard Medical School, Boston, MA; ¶Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI; #Department of Psychiatry, Massachusetts General Hospital, Boston, MA; **Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda; ††Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI; and ‡‡School of Pharmacy and Pharmacology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Lynn T
authors.initials: LT
authors.lastname: Matthews
authors.forename: Cecilia
authors.initials: C
authors.lastname: Milford
authors.forename: Angela
authors.initials: A
authors.lastname: Kaida
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Ehrlich
authors.forename: Courtney
authors.initials: C
authors.lastname: Ng
authors.forename: Ross
authors.initials: R
authors.lastname: Greener
authors.forename: F N
authors.initials: FN
authors.lastname: Mosery
authors.forename: Abigail
authors.initials: A
authors.lastname: Harrison
authors.forename: Christina
authors.initials: C
authors.lastname: Psaros
authors.forename: Steven A
authors.initials: SA
authors.lastname: Safren
authors.forename: Francis
authors.initials: F
authors.lastname: Bajunirwe
authors.forename: Ira B
authors.initials: IB
authors.lastname: Wilson
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Smit
mesh_terms: D000328:Adult; D001294:Attitude to Health; D044383:Black People; D003267:Contraception / Q000523:psychology; D005260:Female; D005306:Fertilization; D017144:Focus Groups; D015658:HIV Infections / Q000517:prevention & control / Q000523:psychology / Q000635:transmission*; D006679:HIV Seropositivity / Q000635:transmission; D006282:Health Personnel; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000517:prevention & control*; D021841:Safe Sex; D012731:Sex Counseling / Q000379:methods*; D012747:Sexual Partners / Q000523:psychology*; D013019:South Africa