Reproductive intentions and corresponding use of safer conception methods and contraception among Ugandan HIV clients in serodiscordant relationships

Among people living with HIV in Uganda, unplanned pregnancies and desires to have a child and are both common. However, use of modern contraceptives and methods to safely conceive [safer conception methods (SCM)] are low. A sample of 389 HIV clients who reported considering childbearing with their uninfected partner was enrolled. Data were examined to identify factors associated with whether or not the client and their partner wanted to and were actively engaged in trying to conceive a child, and their corresponding use of SCM or contraception.

Most (n = 313) 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 knowledge of SCM and less perceived stigma of childbearing. Less than a third (n = 117 of 385 with data; 30.4%) participants 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 their relationship, and greater perceived acceptance of SCM in their community.

Among those who had tried to conceive, only 14 (11.9%) used SCM, which was associated with greater control in decision making within their relationship. 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.

In conclusion, methods to promote reproductive goals are underused by couples living with HIV, and relationship characteristics and childbearing-related stigma appear to be most influential and thus targets for intervention.

Across sub-Saharan Africa, including Uganda, reproductive health and family planning services have been integrated into HIV care [1]. In Uganda, and throughout the region, family planning services historically and currently focus exclusively on preventing unplanned pregnancies. Services to support safer conception are not present, despite 20–60% of people living with HIV (PLHIV) in Uganda wishing to conceive [2‐7] and up to 40% of HIV-positive women becoming pregnant post-HIV diagnosis [7, 8]. About half of these pregnancies are planned [7], highlighting the need for family planning programs to include safer conception counseling (SCC), while the unplanned pregnancies reveal a high unmet need for more effective contraception promotion. With 60% of HIV-affected couples in Uganda being serodiscordant [9], there is a clear need for a more expansive view of family planning services that help PLHIV and their partners to make informed childbearing decisions, and use effective methods for either safely conceiving and delivering a child, or preventing unwanted pregnancies.

Antiretroviral therapy (ART) greatly reduces the transmission risks related to childbearing [10], but in Uganda ~ 30% of PLHIV are not on ART [11], ~ 30% of those on ART have suboptimal adherence (including women on ART for prevention of mother-to-child transmission) [12, 13], over a third of PLHIV have unsuppressed viral load [11], and pre-exposure prophylaxis (PrEP) continues to not be widely available. These all point to the need for using safer conception methods (SCM) such as timed condomless intercourse and manual self-insemination as a compliment to ART. In our prior observational prospective study of PLHIV in Uganda who were trying to conceive, 35% used timed condomless intercourse and just three participants used manual self-insemination, at any time during the 24-month follow-up [14]; however, clients expressed a willingness to use these methods if properly instructed [15]. Our research revealed individual (low SCM awareness; internalized childbearing stigma), partner (HIV non-disclosure; partner willingness to use SCM or attend SCC), and provider (childbearing stigma; lack of SCC knowledge and training) level barriers to SCM use [14, 16].

Our prior research also suggests that HIV-serodiscordant couples who are considering childbearing may decide to delay pregnancy, especially if both members are not certain about wanting a child or if health concerns need to first be resolved [17]. However, studies that have examined fertility desires among PLHIV have often neglected to measure contraception use and intentions. A recent large study found that less than half (43%) of HIV-positive women in Uganda use modern contraceptives; the rate was higher (60%) among those who reported trying to delay or prevent pregnancy [18], but this is still relatively low for achieving their goal of preventing pregnancy.

To help clients and couples achieve optimal reproductive health outcomes, a better understanding is needed with regards to how couples communicate and make decisions about childbearing, including whether or not to have a child as well as the best timing of the pregnancy, and to use either SCM or contraception to achieve what they conclude is their desired pregnancy goal. This knowledge will then better position SCC to help couples progress through these processes that result in decisions and actions towards this goal.

In the context of a larger longitudinal controlled trial of a SCC intervention for Ugandan HIV clients in serodiscordant relationships, we sought to address these important gaps in the literature. Using baseline data, before exposure to any intervention, we explored the following research questions: 1) What differentiates couples who agreed about wanting a child now from couples where at least one member did not want a child now? 2) Among couples who wanted a child now, what differentiates those who had been trying to conceive, from those who had not? 3) Among couples who had been trying to conceive, what differentiates those who report use of SCM from those who report no use of SCM? 4) Among couples who had not been trying to conceive, what differentiates those who report current modern contraception use from those who were not using contraception?

In this sample of HIV clients who reported considering having a child at enrollment, the vast majority reported that both they and their partner wanted to have a child right away. Nevertheless, less than a third of these clients had recently been trying to conceive. Among those who had been trying to conceive, just 1 in 10 were using SCM, with timed condomless intercourse being almost the sole method used. Conversely, among those who reported not trying to conceive, only one quarter reported current use of modern contraceptives, while just over half reported using some type of method (contraceptives, consistent condom use, abstinence) to prevent pregnancy. Relationship characteristics and perceived community attitudes towards pregnancy among PLHIV were among the independent correlates of intentions and behaviors aimed at conception, while self-agency in decision making was an independent correlate of use of both SCM and contraception. Individual-level constructs related to the ecological adaptation of the Information Motivation and Behavioral skills model of health behavior were not prominent as correlates of these reproductive decisions and behaviors, particularly when controlling for other variables associated with the behavior.

Most but not all reported agreement between themselves and their partner on the desire for and timing of pregnancy. Participants who were married to their partner, been together with their partner longer, and had no prior children with their partner, were more likely to report that both they and their partner wanted a child now, suggesting that those in stable relationships are more likely to be motivated to want a child sooner rather than later. This appears to be especially true when they have had no prior children together, which culturally is considered to be important for legitimizing and securing a relationship in Uganda [20‐22].

Participants who reported that both they and their partner wanted a child now also had greater SCM knowledge, and less internalized stigma about childbearing, despite perceiving greater stigma from the community regarding childbearing among PLHIV. These findings suggest that having more information about how to have a safe, healthy pregnancy and not feeling shame or stigma about wanting a child as someone living with HIV, enables a couple to feel empowered to want to have a child, even in the face of perceived stigma in the community. Furthermore, having greater SCM knowledge may serve as a buffer against the effects of external stigma, as such couples may understand that they are able to prevent transmission of HIV to the child and partner, as this is what likely drives community concerns about pregnancy in this population. The greater perceived stigma in the community may also be a biproduct of lower internalized stigma and shame which may lead one to talk more about wanting and trying to have a child, which may increase exposure to stigmatizing views from others. Couples living with HIV, perhaps especially those in serodiscordant relationships who are yet to have children together, are likely weighing the opposing pressures of needing to have children to legitimize their marriage (particularly if they have not disclosed their HIV status to family and friends), and wanting to avoid stigma and shame from others about having a child and risking transmission of HIV to both the child and uninfected partner [23]. Which of these pressures is most influential will vary across couples, and may have played a role in our observation that a minority of couples who wanted to have a child were actually trying to conceive.

Although the vast majority said both they and their partner wanted a child now, just under a third of such respondents said they had been trying to conceive in the months prior to enrollment. Trying to conceive was associated with the index participant (and HIV-positive member of the couple) being female, and having less agency in decision making within the relationship. In Uganda, cultural norms dictate that women have less control over decisions [20], and this may extend to decisions and behaviors related to sex and childbearing [24], so women are more vulnerable to being pressured by their partners to try to conceive [20]. The fact that all the women (whether they were an index participant or HIV-negative partner) in this part of the analysis were indicated as having a desire to have a child now, would seem to negate the potential for the woman to be pressured by the man to seek childbearing, but it is possible that some of these women felt pressured either by their partner or others (e.g., family, community) to express a desire to have a child now [2, 8, 25]. Not having prior children with one’s current partner was another independent correlate of trying to conceive; as stated above, this is a clear motivator for not only wanting a child now, but also actively trying to conceive. Trying to conceive was also associated with greater perceived cultural acceptability of SCM in the community, which suggests that perceived support or acceptance for strategies to ensure a healthy, safe pregnancy among PLHIV may help a couple to decide to move forward with trying to conceive.

Among those trying to conceive, just 1 in 10 were using SCM, with timed condomless intercourse being the method used most. Important to note is that not a single participant reported implementing these methods accurately. Knowing how to determine the timing of the 3-day fertile period for the woman seemed to be the most challenging aspect for implementing timed condomless intercourse and manual self-insemination. These findings are likely in part a reflection of the general low knowledge of SCM and how to properly implement the methods, as also found in our prior research [15‐17]. Use of SCM was associated with having more self-agency or control in decision making within the relationship, which suggests that SCM are more likely to be used if the members of the couple feel they have a say in their childbearing decision process. Safer conception counseling (SCC) helps to promote autonomy and self-agency in the context of childbearing decisions by facilitating an informed decision making process in which the couple receives information and instruction about what contributes to a healthy pregnancy, and increased access to SCM by informing couples about timed condomless intercourse and manual self-insemination, as well as support to implement these methods [26]. Our prior qualitative research suggests that these couples are willing to use these methods with proper instruction [15, 17], further highlighting the need for SCC to ensure uptake and effective use of SCM.

Among those who reported not trying to conceive in the months leading up to baseline, just one in four reported using modern contraceptives at the time of the baseline interview. This is much lower than the 68% found in a recent large study of HIV-positive women in Uganda who were seeking to prevent pregnancy [18]. While the respondent and their partner may not have yet been in a position to agree on actively pursuing pregnancy prior to baseline, some level of desire to have a child was present within the relationship (given our enrollment criteria). This desire may serve as a strong barrier to contraception use, particularly in the larger context of cultural pressure to have children. Being with one’s partner for a shorter period of time was associated with using modern contraception, while those who already had biological children were much more likely to be using some method (contraception, condoms, abstinence) to prevent pregnancy, further highlighting how one’s relationship context can influence reproductive behaviors.

Use of modern contraceptives was also associated with lower depression and greater positive attitudes towards contraception [27]. Better mental health and psychological well-being is conducive to making lucid, coherent decisions and better health behavior, as well as motivation to engage in behavior that is consistent with one’s goals [28], including contraception to prevent pregnancy [27]. Unfortunately, mental health problems, including depression, largely go undetected and untreated in low resource settings, including Uganda [29]. Greater priority on depression screening and treatment is needed in all health settings, but especially in HIV primary care and family planning for the population targeted in this study. These findings also suggest the importance of having positive attitudes and beliefs regarding modern contraceptives, which is likely related to greater knowledge and understanding about how modern contraceptives work and the importance of receiving quality instruction and support from family planning providers. Misconceptions and myths about modern contraceptives are not uncommon in Uganda and the larger region of sub-Saharan Africa [30, 31], as well as other barriers such as stock outs, and health centers often not having all contraceptive types (e.g., intrauterine device, long acting reversible contraceptives). These are all factors that must be addressed to increase uptake and proper use of modern contraceptives.

While a minority of those not trying to conceive right away were using modern contraceptives, just over half (55%) were either using modern contraceptives or consistent condom use (or abstinence). However, given the risk of HIV transmission to the uninfected partner, it is noteworthy that roughly two-thirds of these participants reported inconsistent condom use with their partner, including many who never use condoms. Most of the sample had undetectable viral loads at their last viral load testing, which provides protection against transmission risks, but some level of risk for transmission remains given the uncertain presence of spikes in viremia in between the annual viral load tests that are done as part of usual care. Inconsistent condom use was present, despite the intention to prevent pregnancy, although a desire for children now or in the future was present for most participants or their partners, and this was likely a contributing factor to lack of condom use.

Limitations to this study include the absence of direct data collected from the partner of the index participant, except for female partners of male participants who were briefly interviewed to collect information regarding contraception use. Our data largely relies on the perceptions of the index participant with regards to the attitudes and behaviors of the partner. Other limitations include the reliance on self-reported data, including use of SCM and contraceptives, the cross-sectional nature of the data, and the sample being comprised solely of PLHIV who are receiving HIV care. Clinic data related to prescription of contraceptives would strengthen our data regarding contraception use. The cross-sectional nature of the data enables us to examine associations but not causality or even temporal inferences, the latter of which may be possible with the longitudinal data to be collected in this study. With the sample being limited to those in care, our findings may not reflect PLHIV who are not in HIV care and perhaps less likely to be familiar with safer conception and contraception methods and how to use them.

Our findings offer suggestions for how health services can better support the desired pregnancy goals of clients and couples affected by HIV. First, providers need to understand what clients and their partners have discussed and how they have made their current childbearing decisions, including consideration of past attempts to conceive. Providers need to recognize the influence of partners and the relationship on these decisions, as well as the impact of perceived community attitudes towards PLHIV having children. They also need to take into account the sex of the HIV-positive partner and self-agency in relationship decision making as potential drivers of childbearing decisions and behaviors. SCC is a process through which counselors can facilitate couple communication and decision making regarding the best timing of the pregnancy, as well as use of safer conception or contraceptive methods to achieve their desired reproductive outcome. SCC is an opportunity to empower couples to make informed decisions and take appropriate actions to achieve their desired goals, and such counseling can promote both members of the couple having a say in their childbearing decisions, provide information that can address negative attitudes towards contraceptives, and facilitate access to services that can address mental health needs. Finally, given the influence of perceived stigma in the community towards childbearing among PLHIV, it is important to educate communities on the reproductive rights and choices available to HIV affected couples and the clinic support services that can facilitate safer conception to minimize the risk of HIV transmission to either the child or the uninfected partner.