Correlates of Use of Timed Unprotected Intercourse to Reduce Horizontal Transmission Among Ugandan HIV Clients with Fertility Intentions

Abstract

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.

Appendix

Items of scales developed to assess knowledge and attitudes related to safer conception methods, and stigma of childbearing among people living with HIV/AIDS.

Knowledge of Safer Conception Methods (15 items)

Response options: True, false, don’t know.

• 1. It is possible for an HIV+ woman to have an HIV-negative baby.

• 1. It is possible for an HIV+ woman to have an HIV-negative baby.

• 3. There are ways to make conception with an HIV+ partner safer.

• 4. There are ways to make conception with an HIV-negative partner safer.

• 5. All options to make conception safer are very expensive. (Item skipped if respondent indicates that statements 3 and 4 are false).

• 6. Waiting until my CD4 count is high will reduce the risk of health complications to the mother during the pregnancy.

• 7. Having a sexually transmitted infection will increase the risk of passing HIV to an uninfected partner during unprotected or “live” sex.

• 8. There are times during a woman’s cycle when she is most fertile (likely to become pregnant).

• 9. Health care providers can offer advice to help make childbearing safer for you, your partner, and your child.

• 10. If an HIV+ person has an undetectable amount of HIV virus, it means that person is no longer able to infect someone else.

• 11. For some couples, having the man ejaculate into a condom or container and then manually inject the semen into the woman’s vagina is a way to reduce risk of HIV transmission if the man is HIV negative.

• 12. Only having unprotected sex during the few days each month when the woman is most fertile will help to limit the risk of HIV transmission to an uninfected partner.

• 13. There is technology available that can cleanse a man’s sperm or semen of the HIV virus.

• 14. Starting to take HIV medications early (as soon as diagnosed) helps reduce the risk of transmitting HIV to a sexual partner.

• 15. HIV medications can be taken by an HIV-negative (or unknown status) partner that will reduce their risk of getting infected by their HIV+ partner.

Cultural Acceptability of Safer Conception Methods (6 items)

Response options: Strongly disagree, somewhat disagree, somewhat agree, strongly agree.

• 1. When deciding whether or not to have a child, it is appropriate to involve a health care worker in that decision.

• 2. It is realistic to ask one’s partner to delay conception until the HIV + partner’s CD4 count is high enough.

• 3. Couples living with HIV are able to restrict unprotected sex to only 2–3 specific days per month, when the woman is most fertile, if it helps to conceive a child more safely.

• 4. Involving a health care provider in our conception efforts will be beneficial.

• 5. HIV+ partners would be willing to start HIV medications early (as soon as diagnosed) if they knew it would reduce their risk of transmitting the virus to a partner.

• 6. HIV negative partners of HIV+ patients would be willing to take HIV medications every day during the months in which they were trying to conceive in order to reduce their risk of infection.

Self-efficacy Regarding Use of Safer Conception Methods (7 items)

Response options: Rating of confidence rating from 1 ‘can’t do at all’ to 10 ‘certain I can do’.

• 1. I can discuss safer conception options with my partner.

• 2. I can ask a provider for help in planning a pregnancy.

• 3. I can follow advice about postponing attempts to conceive until any sexually transmitted infections are treated.

• 4. I can follow advice about limiting unprotected sex to only 2–3 specific days per month.

• 5. I/my partner can learn how to track the most fertile days in a woman’s cycle.

• 6. My partner can ejaculate into a container or a condom during sex and then inject the semen into my vagina if necessary to reduce the risk of transmission to my partner. (Item only asked if respondent was female and male partner’s HIV status is negative or unknown).

• 7. My partner can take HIV medications every day during the months we try to conceive if it reduces his/her risk of getting infected with HIV. (Item asked only if partner’s HIV status is negative or unknown).

Motivation to Use Safer Conception Methods (6 items)

Response options: Rating of agreement from 1 ‘strongly agree’ to 10 ‘strongly disagree’.

• 1. It is important to me to work with a health care provider to plan a pregnancy.

• 2. I want to discuss conception options with my partner before we try to have a child.

• 3. I’m confident a health care provider can be helpful to me and my partner in trying to have a child safely.

• 4. I feel it is important to include my partner in this discussion about safer childbearing.

• 5. I am willing to go about conception in a non-traditional manner if it will reduce the risk of transmission to an uninfected partner.

• 6. I am ready to temporarily delay getting pregnant if it helps me to have a child more safely.

Perception of Partner’s Willingness to Use Safer Conception Methods (5 items)

Response options: Rating of confidence from 1 ‘no confidence’ to 5 ‘high confidence’.

• 1. Partner would attend a doctor visit with you to learn about safer ways to conceive a child.

• 2. Partner would be open to trying methods to reduce risk during conception.

• 3. Partner would be willing to wait to have unprotected or “live” sex until your/both of your CD4 counts are at a high level.

• 4. Partner would cooperate with advice to only have unprotected sex during 2–3 peak fertility days per month.

• 5. Partner would cooperate with advice to have sex with a condom so that his semen could be contained and then injected into your vagina in order to reduce the risk associated with trying to conceive a child. (Item asked only if partner was male and HIV status was negative or unknown).

Internalized Childbearing Stigma (4 items)

Response options: Disagree strongly, disagree slightly, neutral, agree slightly, agree strongly.

• 1. I feel ashamed for wanting to have a child.

• 2. I feel selfish for wanting to have a child.

• 3. HIV+ persons who want to have a child should feel embarrassed to tell their HIV provider.

• 4. People living with HIV can be good parents. (Item reversed before scoring).

Perceived Social Childbearing Stigma (4 items)

Response options: Disagree strongly, disagree slightly, neutral, agree slightly, agree strongly.

• 1. Family members who know I am HIV+ will not approve of me wanting to have a child.

• 2. People in the community look down on HIV+ individuals who want to have a child.

• 3. An HIV+ man who gets his partner pregnant is looked down upon.

• 4. An HIV+ woman who gets pregnant is looked down upon.

Perceived Provider Childbearing Stigma (1 item)

Response options: Disagree strongly, disagree slightly, neutral, agree slightly, agree strongly.

• 1. Most HIV providers think that HIV+ clients should not have children.