Multiple Perspectives on Safer Conception for Women Living with HIV in Botswana: Implications for Service Delivery

Abstract

HIV-affected couples in sub-Saharan Africa continue to desire childbearing. With high repeat pregnancy rates among women living with HIV and HIV sero-discordance rates close to 50% among couples in sub-Saharan Africa, it is imperative to address the reproductive needs of women living with HIV. Low-cost safer conception (SC) methods to limit HIV transmission risks within HIV sero-discordant couples can be made available in resource-constrained settings. However, SC services are underutilized in many high HIV prevalence countries, including Botswana. In order to develop culturally appropriate programs, research is needed that identifies feasible and acceptable targets for SC interventions. Therefore, this dissertation explores issues around childbearing and pregnancy planning, perceptions of different SC methods, and the correlates of SC information, motivation, behavioral skills, and self-efficacy. The research for this dissertation was conducted in collaboration with local Batswana HIV activists, community-based organizations, and women living with HIV. In addition, the in-country research team was composed of Batswana women who collected data in the local language. Our team first conducted individual in-depth interviews with HIV healthcare providers (n=10) and women living with HIV (n=10) to develop a deeper understanding of attitudes surrounding childbearing and pregnancy planning. Interviews were qualitatively analyzed using an interpretive phenomenological approach. Providers reported it was a human right and normative for women living with HIV to have children but also expressed hesitancy about women living with HIV having children. Although providers believed pregnancies amongst women living with HIV were unplanned, women described discussing pregnancy desires with sexual partners. Participants shared that women living with HIV anticipated stigma from providers regarding childbearing. Following that study, our team conducted eight focus group discussions with women living with HIV (n=45) to gain an in-depth understanding of their perceptions regarding different SC methods, including perceived benefits and challenges of each. These qualitative data were analyzed using an interpretive phenomenological approach. Key factors influencing method perceptions reflected issues at the individual (knowledge of methods, personal motivation to protect partners from HIV transmission, and risks), interpersonal (partner support and communication, relationship intimacy, reducing partner transmission risks, provider stigma), health systems (access and availability, cost of methods, human resource shortages), policy (Ministry of Health policies), and socio-cultural levels (cultural acceptability of methods, norms of masculinity). Although a lack of prior SC knowledge and counseling was a noted challenge to uptake, women were interested in pre-exposure prophylaxis (PrEP) and vaginal insemination techniques for SC. Finally, our team conducted cross-sectional surveys amongst women living with HIV (n=356) to identify areas to target in SC interventions. We estimated four multiple linear regression models to examine factors associated with SC information, motivation, behavioral skills, and self-efficacy. The analyses revealed that while male circumcision was a SC method that was well known (83%), and the use of ART for viral suppression was known by 64% of participants. Most other methods, including vaginal insemination, PrEP, timed unprotected intercourse, and sperm washing were known by 40% of participants or less. In addition, we found that relationship and partner factors, reproductive autonomy, elements of stigma, and provider factors affect SC information, motivation, behavioral skills, and self-efficacy. These are the first SC studies in Botswana and the results highlight factors at multiple levels that need to be addressed to successfully offer SC in Botswana and similar contexts. Implications and future directions for this work are discussed.