Reproductive decision-making among postpartum HIV-infected women in rural South Africa

Abstract

Despite pregnancy spacing recommendations to optimize health outcomes among mothers and neonates, unplanned pregnancy in sub-Saharan Africa is common among women living with human immunodeficiency virus (HIV) (WLHIV). This study examined factors associated with reproductive decision-making among WLHIV to inform pregnancy-planning interventions. WLHIV in rural South Africa (n = 165) were assessed at 12 months postpartum. The relative importance of factors associated with reproductive decision-making was estimated. Women were a mean of 28 years old (SD = 5.71). Risk of mother-to-child transmission (MTCT) of HIV (Mean = 0.43; SD = 0.33) had the greatest impact on decision-making, followed by partners’ desires (M = 0.22; SD = 0.18), family preferences (M = 0.18; SD = 0.13), and community opinion (M = 0.17; SD = 0.13). MTCT was most important to women with greater HIV knowledge. However, WLHIV who had been diagnosed with HIV for a longer time placed more emphasis on partner preference and community opinion, and less importance on MTCT risk. Prevention of mother-to-child transmission (PMTCT) was less important to women experiencing intimate partner violence and those with depression. Findings highlight the need for tailored, focused interventions to support the unique circumstances of WLHIV and support the inclusion of families and/or partners in the counseling process. Results underscore the need for perinatal preconception counseling for women during routine HIV care.

Keywords

HIV prevent mother-to-child transmission South Africa women decision-making

Introduction

Antiretroviral therapy (ART) for the treatment of human immunodeficiency virus (HIV)¹ has decreased the probability of mother-to-child transmission (MTCT) to 5% among breastfeeding HIV-infected women.² However, about 30% of women living with HIV (WLHIV) with childbearing intentions are not on ART to prevent mother-to-child transmission (PMTCT),^2–4 and extensive variation exists in retention rates and effectiveness of national ART and PMTCT programs. Attrition rates following ART initiation range from 22% to 50%, and even when provided with medication, not all pregnant WLHIV follow through with treatment.^2,5,6 Public health initiatives to prevent vertical and horizontal transmission and promote pregnancy planning are therefore needed to achieve optimal health outcomes in neonates and mothers.

In South Africa, nearly 50% of pregnancies are unintended and despite pregnancy spacing recommendations, many women become pregnant within 12 months postpartum.⁷ While the method by which couples conceive is understood, the process by which women elect to accept the potential of pregnancy is less clear, as this requires consideration of a combination of co-occurring factors. Conjoint analysis, a quantitative method that has previously been used in the healthcare field,^8–10 examines the relative contribution of co-occurring elements, thereby more accurately replicating the complexity of real-world decision-making. Factors influencing reproductive intentions among WLHIV in southern Africa include family pressure to have additional children^8,11–14; partner desire^1,14–18; potential HIV transmission to neonates,¹⁶ and community childbearing perceptions.^{1,14,16,19–21} Partners play an important role in decision-making; masculinity is associated with male partners’ pressure to have children,^14–18 though WLHIV may avoid childbearing due to fears of revealing their HIV status and ensuing partner violence.^14,16,22 WLHIV may also avoid becoming pregnant due to fear of vertical transmission and infant mortality,¹⁶ though abandonment and financial insecurity have been associated with being childless.^8,11–14 Community opinions regarding WLHIV having children are also influential; WLHIV may avoid childbearing due to fear of social stigma and discrimination associated with having an HIV-infected child or having their HIV status revealed to community members.^1,16,19–21 Nonetheless, WLHIV also feel internal and external pressure to conceive and to ensure their status within their community.¹⁴

This study examined psychosocial factors associated with women’s reproductive decisions. It was hypothesized that decisions would be predominantly influenced by the risk of HIV transmission to infants, partners’ preferences, and community pressure. It was hoped that findings could guide tailored pre-conception planning interventions and enhance PMTCT efforts.

Methods

Consent

Institutional and ethical review board approval was obtained in the US and South Africa before the start of the study. Prior to enrollment, all participants provided written informed consent.

Setting and participants

The study presents data from participants (n = 165) recruited from 12 community health centers with high MTCT rates in the Gert Sibande and Nkangala districts in Mpumalanga province, South Africa. Participants were women enrolled in an ongoing clinical trial to enhance PMTCT (clinicaltrials.gov, NCT02085356).^23,24 Intervention participants attended interactive group and individual sessions on PMTCT with a focus on male involvement during pregnancy in addition to the standard of care; enhanced control condition participants attended group video presentations on child health in addition to the standard of care. Both conditions have been previously described.²⁴ Women were enrolled in the study when 4–6 months pregnant and were HIV seropositive and over the age of 18; the current analysis examines women at 12 months postpartum and includes women in both intervention and control conditions.²³ Conjoint and demographic interviews were conducted using an audio computer assisted self-interview (ACASI) system in the preferred language of respondents (i.e., isiZulu, Sesotho, English). ACASI was used to reduce response bias and to enable those with low literacy to respond to the questionnaire.²⁴

Assessment measures

Socioeconomic status information assessed included age, education, and monthly income. Reproductive questions included number of children, the planned versus unplanned nature of the most recent pregnancy, and family planning discussions with healthcare providers. HIV-specific issues included HIV and PMTCT knowledge and the time since the HIV diagnosis (during or before current pregnancy). The HIV knowledge measure was an adapted 12-item scale (Cronbach’s α = 0.69, 0.64, 0.52, and 0.65, respectively, at two prenatal and two postnatal assessment points). Questions addressed HIV transmission, reinfection, and condom use; participants were asked to respond to each item with “Yes,” “No,” or “Don’t know.” Higher correct responses represented greater knowledge and were categorized at the median as “High” HIV knowledge or “Low” HIV knowledge. PMTCT knowledge was evaluated using a six-item scale (Cronbach’s α = 0.71, 0.66, 0.65, and 0.78 at the four assessment points), with questions such as, “Can a HIV-positive mother infect her baby with HIV during delivery?” PMTCT knowledge scores were similarly dichotomized into “High” and “Low” knowledge categories utilizing the median.^25,26

Partner questions included living arrangements (cohabiting or living apart from partner), HIV status disclosure to partner, knowledge of partner's HIV status, male partner involvement during pregnancy, physical intimate partner violence (IPV), and psychological IPV. HIV disclosure was assessed using a modified version of the Disclosure Scale.²⁷ The Male Involvement Index (MII) was used to assess the degree of men’s participation during pregnancy (α = 0.84)^3,28,29 and consisted of 11 items scored dichotomously.³ MII scores were dichotomized using the median. IPV was assessed using a modified version of the Conflict Tactics Scales (CTS).^30,31 Scores were dichotomized into “Yes” or “No” categories: presence or absence of psychological and/or physical IPV. The CTS subscales have demonstrated adequate internal reliability, i.e. reasoning (α = 0.70), psychological (α = 0.83), physical violence (α = 0.91).³¹

Psychological factors

Depression was evaluated using The Edinburgh Postnatal Depression Scale 10 (EDPS-10), a ten-item questionnaire asking respondents to rate depressive symptoms in the last seven days³² and has been validated with South African populations. A score of 12 suggests depression³³ (α = 0.75).^3,31 Perceived HIV stigma was assessed using the AIDS-Related Stigma Scale,³⁴ a nine-item scale, e.g. “People who have AIDS should be ashamed.” Respondents are asked to code statements as “disagree” or “agree”; higher scores indicate greater stigma. Previous studies have reported adequate reliability (α = 0.75).^3,34

Conjoint questionnaire

The conjoint questionnaire utilized four attributes previously identified as important motivators of pregnancy among WLHIV: family pressure to have children^8,11–13; partner desires to have children^1,15–18; the risk of HIV transmission to neonates¹⁶; and community perceptions regarding childbearing.^1,16,19–21 Each attribute was assigned a positive, negative, and neutral valence, e.g. positive (e.g. “People say you should have a baby”), neutral (e.g. “People do not care if you have a baby or not”) and negative (e.g. “People say you should not have a baby”). A subset of 12 representative scenarios was generated through SPSS software and is presented in Table 1. Each scenario was accompanied with pictorial representations to assist respondents in understanding and conceptualizing the scenario.

Table 1.

Conjoint scenarios.

How much would you want to have a baby if:
Your partner DOES NOT CARE if you have a baby or not. There is VERY HIGH RISK of HIV infection for the baby. People say you SHOULD HAVE a baby. Your family DOES NOT CARE if you have a baby or not	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner DOES NOT WANT to have a baby There is NO RISK of HIV infection for the baby People DO NOT CARE if you have a baby or not Your family says that you SHOULD NOT have a baby	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner DOES NOT WANT to have a baby. There is VERY HIGH RISK of HIV infection for the baby. People say you SHOULD NOT have a baby. Your family says that you SHOULD NOT have a baby	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner DOES NOT CARE if you have a baby or not. There is SOME RISK of HIV infection for the baby. People say you SHOULD NOT have a baby. Your family DOES NOT CARE if you have a baby or not	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner DOES NOT WANT to have a baby. There is SOME RISK of HIV infection for the baby. People DO NOT CARE if you have a baby or not. Your family DOES NOT CARE if you have a baby or not	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner DOES NOT CARE if you have a baby or not. There is NO RISK of HIV infection for the baby. People DO NOT CARE if you have a baby or not. Your family DOES NOT CARE if you have a baby or not	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner DOES NOT WANT to have a baby. There is NO RISK of HIV infection for the baby. People say you SHOULD have a baby. Your family says that you SHOULD have a baby	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner WANTS to have a baby. There is NO RISK of HIV infection for the baby. People say you SHOULD NOT have a baby. Your family DOES NOT CARE if you have a baby or not	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner WANTS to have a baby. There is VERY HIGH RISK of HIV infection for the baby. People DO NOT CARE if you have a baby or not. Your family says that you SHOULD have a baby	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner DOES NOT CARE if you have a baby or not. There is SOME RISK of HIV infection for the baby. People say you SHOULD NOT have a baby. Your family says that you SHOULD have a baby	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby
Your partner WANTS to have a baby. There is SOME RISK of HIV infection for the baby. People say you SHOULD have a baby. Your family says that you SHOULD NOT have a baby	Please choose from option: 1 means that you would NOT want to have a baby at all, 10 means that you would REALLY want to have a baby

Conjoint analysis

Conjoint analysis assumes that each attribute (family pressure to conceive, partners’ desire to have a child, etc.) contributes additively to the decision process, and that a respondent will choose the scenario with the highest perceived utility, or value. Each of the attributes has a particular weight or utility in the decision process. That utility value is a coefficient known as “part-worth utility” and is calculated using a least-squares linear regression model. The larger the part-worth utility, the larger the influence of that attribute. The overall importance or influence an individual attribute is standardized by dividing the total variation in that particular part-worth utility by the sum of the variations of all part-worth utilities and multiplying the result by 100.^35–37 The importance and utility scores of all respondents were thus calculated individually, then averaged and represented through descriptive statistics.^8,10

Statistical analysis

Descriptive analyses were utilized to characterize the participants. To calculate importance scores for each participant, conjoint analysis was performed using women’s ratings for each scenario. Utility coefficients or scores for each of the attributes (i.e. partners’ and families’ preferences, risk of MTCT of HIV, and community opinion) for each woman were estimated using ordinary least-squares regression. To standardize utility values and transform them into relative importance scores for each of the attributes, values were transformed into a percentage scale by subtracting the highest utility value from the lowest, then dividing the result by the sum of all the utility ranges, and then multiplying them by 100. As such, a relative importance score for each of the respondents was obtained, which were then used as data for further analyses.

To evaluate the associations between demographics and reproductive, HIV, partner, and psychological issues, and the relative importance attributed to each of the factors by women, t tests, analyses of variance, and Pearson bivariate correlations were used. Given that the standardization of utility scores normalizes the distribution of importance scores, these parametric analyses were the most appropriate to use. The validity of the data obtained from the conjoint questionnaire ratings was tested using “holdout” profiles.^35,36 Holdout profiles are intended to assess the fit between the conjoint model and actual participant ratings. No differences between model predictions and actual ratings were found (b = −0.117 (0.89), p = 0.345), suggesting that the fit of the conjoint model was adequate. Statistical significance for all analyses was defined as a p < 0.05. Conjoint analyses were conducted using SPSS Statistics for Windows v22.

Results

Demographic characteristics

Women were a mean age of 28 years (SD = 5.71), 51% had 10 to 11 years of education and a monthly household income of ≥ SAR600 (∼USD$70). Most (81%) had at least one child, 59% reported an unplanned pregnancy, and 86% reported having discussed prevention of perinatal MTCT of HIV with their provider. Nearly half (47%) of women had been diagnosed with HIV during the current pregnancy, 44% had high HIV knowledge and 47% had high PMTCT knowledge. HIV disclosure to partners was reported by 54% and 30% reported that their partner was HIV-infected. Partner involvement was endorsed by 49% of women; 59% reported psychological IPV and 22% physical IPV. Almost half (46%) of women reported depressive symptoms and 76% reported perceived HIV stigma. Women participating in the control condition were more likely to report being influenced by concerns about HIV transmission to neonates (p = 0.02).

Relative importance of risk of MTCT of HIV, partners’ and families’ preferences, and community opinion in reproductive decision-making

Prevention of HIV transmission to infants (Mean = 0.43) had the greatest impact on reproductive decision-making, followed by partners’ desires (M = 0.22), family preferences (M = 0.18), and community opinion (M = 0.17). Women who placed the most importance on partner preference had lower HIV knowledge and were more likely to have HIV infected partners. Women who placed more importance on PMTCT had discussed a future pregnancy with their provider, had higher HIV and PMTCT knowledge and were less likely to be experiencing psychological IPV or depression. Women who placed greater importance on their family preferences had lower HIV and PMTCT knowledge and were more likely to be experiencing depression. Older women placed more emphasis on community opinion for reproductive decision-making, were more likely to have been diagnosed with HIV prior to the most recent pregnancy and to have discussed future pregnancy with their provider, had less HIV and PMTCT knowledge and were more likely to have experienced psychological and physical IPV. Women participating in the control condition were more likely to report being influenced by concerns about HIV transmission to neonates (p = 0.02). All comparisons are summarized in Table 2.

Table 2.

Partner, vertical transmission, community, and family importance by socioeconomic, reproductive, HIV, partner, and mental health characteristics.

Characteristic	Partner	Vertical transmission	Community	Family
Characteristic	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD) F/t, p
Socioeconomic status
Age	r = 0.12	r = −0.15	r = 0.16	r = 0.05
Age	p = 0.134	p = 0.056	p = 0.043	p = 0.487
Education
Grade 0–9	0.20 (0.13)	0.43 (0.33)	0.16 (0.14)	0.21 (0.15)
Grade 10–11	0.22 (0.18)	0.43 (0.34)	0.18 (0.11)	0.18 (0.14)
Grade 12 or more	0.23 (0.20)	0.43 (0.33)	0.17 (0.13)	0.18 (0.12)
F, p	0.25, 0.781	0.02, 0.985	0.17, 0.844	0.58, 0.563
Monthly household income (South African Rand)
<600 (∼$50)	0.22 (0.18)	0.42 (0.32)	0.17 (0.14)	0.19 (0.14)
≥600	0.22 (0.18)	0.43 (0.34)	0.17 (0.13)	0.18 (0.13)
t, p	0.09, 0.930	0.26, 0.796	0.00, 0.998	0.51, 0.610
Reproductive issues
Number of children
None	0.17 (0.15)	0.53 (0.36)	0.16 (0.14)	0.14 (0.12)
One or more	0.23 (0.18)	0.40 (0.32)	0.17 (0.13)	0.19 (0.14)
t, p	1.69, 0.092	1.89, 0.060	0.45, 0.654	1.95, 0.053
Pregnancy unplanned
No	0.21 (0.17)	0.45 (0.33)	0.16 (0.13)	0.18 (0.13)
Yes	0.23 (0.18)	0.41 (0.33)	0.18 (0.14)	0.19 (0.14)
t, p	0.62, 0.533	0.72, 0.474	0.53, 0.600	0.42, 0.675
Discussed future fertility intentions with provider
No	0.28 (0.14)	0.24 (0.08)	0.26 (0.14)	0.22 (09)
Yes	0.21 (0.18)	0.46 (0.35)	0.16 (0.13)	0.18 (0.14)
t, p	1.76, 0.080	2.95, <0.001	3.44, 0.001	2.00, 0.052
HIV issues
Diagnosed during this pregnancy
No	0.24 (0.19)	0.38 (0.31)	0.19 (0.14)	0.19 (0.13)
Yes	0.19 (0.15)	0.48 (0.34)	0.15 (0.12)	0.18 (0.14)
t, p	1.93, 0.056	1.95, 0.053	1.99, 0.048	0.31, 0.760
HIV knowledge
Low	0.27 (0.16)	0.32 (0.24)	0.20 (0.12)	0.22 (0.12)
High	0.16 (0.17)	0.57 (0.38)	0.14 (0.15)	0.14 (0.14)
t, p	4.08, <0.001	4.91, <0.001	2.88, 0.005	3.90, <0.001
PMTCT knowledge
Low	0.24 (0.15)	0.35 (0.26)	0.20 (0.12)	0.21 (0.12)
High	0.19 (0.20)	0.51 (0.38)	0.14 (0.14)	0.15 (0.14)
t, p	1.83, 0.070	3.21, 0.002	2.69, 0.008	2.77, 0.006
Partner issues
Partner status
Married or cohabiting	0.22 (0.17)	0.42 (0.32)	0.17 (0.13)	0.19 (0.13)
Having partner (not cohabitating)	0.22 (0.19)	0.44 (0.34)	0.16 (0.14)	0.18 (0.14)
t, p	0.01, 0.993	0.35, 0.726	0.41, 0.647	0.41, 0.682
Disclosure of serostatus (to partner)
No	0.20 (0.15)	0.44 (0.33)	0.18 (0.14)	0.19 (0.14)
Yes	0.24 (0.19)	0.42 (0.33)	0.17 (0.13)	0.18 (0.13)
t, p	1.23, 0.207	0.30, 0.762	0.49, 0.626	0.43, 0.671
HIV serostatus of spouse/partner
Negative/do not know	0.20 (0.17)	0.46 (0.34)	0.16 (0.13)	0.18 (0.14)
Positive	0.26 (0.18)	0.35 (0.30)	0.19 (0.13)	0.20 (0.13)
t, p	0.73, 0.036	1.86, 0.053	0.93, 0.352	0.85, 0.398
Male involvement
Low	0.21 (0.15)	0.42 (0.32)	0.18 (0.14)	0.19 (0.14)
High	0.23 (0.20)	0.43 (0.34)	0.17 (0.13)	0.17 (0.13)
t, p	0.95, 0.344	0.14, 0.887	0.51, 0.612	0.38, 0.278
Psychological IPV
No	0.20 (0.18)	0.49 (0.37)	0.15 (0.13)	0.16 (0.14)
Yes	0.23 (0.17)	0.38 (0.29)	0.19 (0.14)	0.20 (0.13)
t, p	1.30, 0.194	2.19, 0.038	2.00, 0.049	1.61, 0.110
Physical IPV
No	0.22 (0.18)	0.44 (0.34)	0.16 (0.13)	0.18 (0.13)
Yes	0.22 (0.16)	0.37 (0.30)	0.21 (0.15)	0.20 (0.14)
t, p	0.16, 0.876	1.23, 0.204	2.03, 0.044	0.91, 0.366
Psychosocial issues
Depression
No	0.21 (0.19)	0.48 (0.35)	0.16 (0.14)	0.15 (0.13)
Yes	0.24 (0.16)	0.36 (0.29)	0.18 (0.13)	0.22 (0.14)
t, p	1.13, 0.262	2.26, 0.023	1.03, 0.304	3.03, 0.003
Stigma
No	0.20 (0.21)	0.48 (0.36)	0.15 (0.12)	0.17 (0.14)
Yes	0.22 (0.17)	0.41 (0.32)	0.18 (0.14)	0.19 (0.13)
t, p	0.61, 0.545	1.17, 0.245	0.98, 0.239	0.88, 0.380

Values in bold are statistically significant.PMTCT: prevention of mother-to-child transmission, IPV: intimate partner violence.

Within the context of the intervention, comparing conditions, importance placed on partners’ preference was greater in the intervention condition than the enhanced control condition (mean = 0.24 [SD = 0.17] versus mean = 0.21 [SD = 0.17] p = 0.009). Importance placed on family opinion was also greater in the intervention condition than the enhanced control condition (mean = 0.23 [SD = 0.13] versus mean = 0.16 [SD = 0.13], p = 0.001). No differences by condition were observed in the level of importance placed on vertical transmission or community opinion.

Discussion

This study examining factors associated with reproductive decision-making among postpartum WLHIV hypothesized that such decisions would be primarily influenced by concerns regarding HIV transmission to infants and partners’ preferences.^5,8 In fact, concerns about transmission to neonates was most important, but partners, family, and community were also associated with reproductive decision-making, and their predominance was influenced by individual factors (women’s HIV knowledge, time since diagnosis, age, and depression), partner factors (HIV status, IPV), and discussions with healthcare providers.^{10,12–14,16–18} Women attending the intervention, which focused on PMTCT and male involvement, were more likely to be influenced by partner and family preferences, which may reflect increased awareness of the role of partner and/or familial support during pregnancy.^3,8

Despite the importance of provider discussions and knowledge regarding HIV and transmission to infants as a foundation for decision-making, their influence was inconsistent and appeared to be outweighed by the perceived importance of child bearing in certain scenarios. Conflicting real-world pressures, such as partner preferences, HIV serostatus, and the recency of an HIV diagnosis create unique pressures for women.^3,14,18 In fact, women placing the most importance on partner preference had lower HIV knowledge and were more likely to have HIV-infected partners, and those placing greater importance on family preferences had lower HIV and PMTCT knowledge and were more likely to be experiencing depression.³⁸ Both findings suggest that women experiencing depression and recent HIV infection may feel less agency to make independent decisions.^{3,16,17,23,39} As such, women placing more importance on PMTCT were less likely to be experiencing psychological IPV or depression, had greater HIV and PMTCT knowledge and had discussed future pregnancy with their provider.^3,40 Women with higher rates of depression may also be less likely to plan for the future and consider the potential for HIV infection of their infant, as depression has been linked to an inability to plan for the future; specifically, WLHIV experiencing depression are less likely to discuss MTCT with providers.⁷ In addition, older women who had experienced psychological and physical IPV and had less HIV and PMTCT knowledge placed more emphasis on community opinion for reproductive decision-making, despite having discussed future pregnancy with their provider and having been diagnosed less recently.^31,40 As a result of having unsupportive male partners to assist with transportation, women experiencing IPV may be less likely to attend clinics, leading to decreased HIV and PMTCT knowledge; women may therefore be forced to rely on community opinion as a source of knowledge and guidance, perceiving these opinions as more valuable in decision-making.⁴¹ These findings highlight importance of treating depression among pregnant WLHIV, which has been shown to have deleterious effects on both WLHIV and their infants.^42,43 However, given that South Africa allocates less than 1% of their health budget to mental health treatment, cost-effective strategies and brief interventions in the context of perinatal care should be explored in future research.⁴⁴

This study had some limitations that should be considered in interpreting the results. The data were drawn from an ongoing study aiming to evaluate the role of men in PMTCT efforts, which may have influenced women’s responses in the intervention arm or may have influenced the responses to questions regarding partner preferences.^14,17,45 An additional limitation is that the conjoint survey may have been perceived as complex by participants; however, a pictorial representation was added to each scenario to facilitate understanding. Future studies could consider examination attitudes in alternative venues, such as antenatal clinic waiting rooms.

These complex relational dynamics highlight the impact of knowledge, maternal depression, and IPV on reproductive decision-making, and the need for individually tailored, focused perinatal interventions to support the unique circumstances of WLHIV.^13,17 The simultaneous presentation of potentially influential factors in reproductive decision-making through the use of conjoint analysis presents a novel analytic strategy to study these complex decision-making processes among WLHIV. Conjoint analysis may also be more ecologically valid and representative of the decision-making process that women may encounter in real-world settings in which they may have to weigh different competing factors with regard to reproductive desires.¹⁰ Findings underscore the need for perinatal preconception counseling for women during follow-up and routine HIV care as well as postpartum; given their influence, physicians should consider inclusion of families and/or partners in the process.^13,17,46 In addition, patients may be unaware that undetectable viral load prevents the transmission of HIV. Current campaigns to increase awareness of lack of transmission, e.g. HIV Undetectable = Untransmittable, may increase adherence and desires for children. As depression has been shown to decrease patient–provider discussions regarding reproductive desires, treating depression may help increase women’s motivation to plan for the future, specifically with regard to reproductive decisions.³ Although family planning discussions are part of the PMTCT protocol, it may also be worthwhile to engage women early on in the HIV care continuum to promote continued discussions surrounding reproductive desires and planning. Innovative strategies may be needed to include male partners in the planning process and to reach women in differing age groups.^5,24,28,47 Making male involvement programs more male friendly may include increasing the number of operating hours to accommodate men’s work schedules, changing cultural beliefs and attitudes that discourage men from participating at the patient and staff level, and increasing clinic space to facilitate the presence of male partners.⁴¹ As a recommendation for all WLHIV, preconception counseling should be integrated into ongoing clinical consultations as windows of opportunity.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by NICHD/NIH grant no. R01HD078187 and with support from P30AI073961.

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