To explore attitudes and feelings about conception, researchers
in Durban, South Africa, conducted in-depth
interviews with 30 women and 20 men living with HIV whose primary partner was
either HIV-negative or of unknown status.
As in the previous study, men often had a stronger desire
than women to have a child, and women with HIV often felt pressure from their
partners to have children. One man explained why he wanted to have a child:
“I think because children
are a gift from God. They leave a legacy of the family and they extend and
expand your surname so that it won’t die when you die, your legacy won’t
perish.”
One woman with HIV said:
“At times he would
pretend he was using the condom when he was not. I told him that we should stop
thinking about having a baby because I am sick, but he had hope that he will
get a child.”
Given the crucial role of men in decisions around pregnancy,
the researchers recommend that male partners must be involved in interventions
to promote safer conception.
But only a few pregnancies were explicitly planned. One
woman said:
“I did want to have a
child but I had not really planned which year it would be, but I wanted one… I was
the one who wanted a child and I’m the only one who knew that. When I told him
[partner] that I was pregnant, he did not have a problem with that.”
Moreover, in these couples, there was considerable confusion
over serodiscordancy. Participants found various explanations for why one
partner was apparently HIV-negative while the other was HIV-positive. Test
results were not always trusted.
“Maybe the virus is
hidden but it is there.”
“He then asked me how
it happens that he is negative and I am positive and I told him about the
window period.”
“I think it’s God’s
will that she did not get the virus from me.”
A number of respondents and partners were fatalistic about
eventual HIV transmission within the couple. This led to riskier behaviour.
Moreover, some HIV-negative male partners were prepared to
risk HIV infection in order to conceive.
“He was the one who
took that decision that he wanted another child. I was afraid. I told him that
what we are doing is not right because he might get infected. And if he is HIV-positive, he will blame me. He said that if it supposed to happen, then it will
happen.”
A few respondents took viral load into account in their
decision making.
“After finding out
that my viral load was very low, even undetectable, he decided that let’s take
a chance and try and see what is going to happen.”
However the majority of respondents were not aware of
strategies such as delaying conception until viral load is undetectable and
self-insemination.
To further explore strategies for safer conception, another
group of researchers interviewed Kenyans who were involved in serodiscordant
relationships. They interviewed both the HIV-positive and HIV-negative
partners, with the aim of better understanding which techniques would be
acceptable to participants.
Some participants were aware of the technique of confining
unprotected intercourse to the female partner’s fertile window, and one couple
had had a baby with this technique (but had not had tested their child for HIV).
But there was scepticism about sperm washing, with one
HIV-positive man commenting:
“It will be so much
expensive, the poor people won’t afford it. The psychological part of it
– the
community
– people will view you as getting a child in a scientific way… in
such a situation, I think you have to take some legal action because you are
not sure that the child who is going to be born is yours. The psychological
part of it might haunt you.”
On the other hand, the idea of pre-exposure prophylaxis
(PrEP) was well received, with its ease of administration being seen as a major
advantage.
“That would be good if
there is a pill that can be taken to prevent infection. It would be good.”
Moreover, most respondents responded positively to the idea
of antiretroviral treatment of the partner living with HIV, in order to reduce
the risk of transmission, although some raised questions about the burden of
side-effects when initiating therapy at a high CD4 count.
A recent UK
study has also found some ambivalence amongst couples about sperm washing,
while the preventative use of antiretroviral therapy was well accepted.
The authors of the Kenyan study conclude that couples
attempting conception are highly motivated to consider interventions to reduce
their transmission risk. With adequate education, they may be open to the use
of HIV treatment, PrEP and timed intercourse.