Cross-sectional studies indicate that people living with HIV are receptive to safer conception advice from providers [33–36], but that healthcare workers (HCWs) are not routinely engaging in conversations about fertility desires or plans, a crucial first piece of any reproductive health intervention [31, 34, 35, 37]. In Cape Town, over 30% of HIV-infected women and 65% of HIV-infected men attending public sector clinics were interested in having additional children, yet only 19% and 6%, respectively, had discussed this with a HCW [38]. Among HIV-infected women in Johannesburg, with plans to conceive in the next year, 40% had ever had a conversation about fertility plans with a provider [34]. Conversations with HCWs about conception plans were also infrequent in Argentina [37], Brazil [39], and the United States [35]. Barriers to these conversations include a combination of patient (e.g., fear of judgment, lack of pregnancy planning), provider (e.g., limited experience, knowledge, or skills), and structural factors (e.g., competing healthcare demands, limited resources, poor integration of family planning and HIV services) [31, 35–37, 40, 41]. While some conversations may be initiated with HIV lay counselors, they may not have the skills to address clinical issues beyond their focused training [42, 43].

Data demonstrating that ARVs minimize HIV transmission suggest that periconception risk-reduction interventions will require HCW involvement [16, 19–22, 27]. In our conceptual framework for periconception risk behavior, HCWs have the potential to minimize risk behavior through providing information about HIV risk, offering prevention strategies, and promoting adherence to risk reduction strategies [44]. There are no data on practices in KwaZulu-Natal, the most HIV-affected province in South Africa, where 41% of pregnant women attending antenatal clinics are HIV positive [45]. A better understanding of current HCW knowledge, attitudes, and practices will enhance the provision of reproductive counseling for HIV-infected individuals by allowing for development of interventions that capitalize on HCW strengths and address weaknesses.

Prior studies suggest that the majority of HIV-infected patients are not receiving reproductive counseling and are reluctant to engage with healthcare workers to discuss reproductive plans [12, 35, 36, 39, 49–51]. Schwartz et al. [34, page 73] presented data collected during 2009 and reported that only 41% of HIV-infected women reported that an “ART healthcare provider had spoken with them about their options should they want to conceive in the future”. In work by Cooper et al., collected in 2006, 19% of women and 6% of men had “consulted a doctor, nurse, or counselor in HIV care about fertility intentions” [38, page S44]. The fact that many participants, including men, in this small sample knew that HCWs may have advice to offer captures data not mentioned in prior studies. These data suggest that clinical settings may be adapting to accommodate the fertility goals of people living with HIV.

Many participants reported the expectation that they could access detailed counseling if they returned to the clinic when they were ready to have a child. From work by our group and others, several facts of periconception practice make this clinical approach precarious. Waiting to talk to a provider until one is ready to have a child eliminates the opportunity to discuss the risks of having children in order to inform the decision to have biologic children [24, 52, 53]. Many men and women living with HIV do not know their partner's status and/or have not disclosed to their partners. Prior to testing and disclosure, it is impossible for an individual or a couple to assess sexual transmission risk in the context of conception. Continued efforts to promote couple-based testing and supported disclosure are critical [54]. For those who decide to have children, a preconception conversation with a healthcare worker should include an assessment of the HIV-infected partner's health; the HIV status of the partner; if the woman is positive, a discussion of the risks of pregnancy when HIV infected; risks of transmission to a partner with various periconception risk reduction strategies; fertility assessment; the increased risk of transmission and acquisition during unprotected sex during pregnancy; the risks of perinatal transmission [44].

Furthermore, asking individuals or couples to return when they are ready to have children presupposes conception planning. However, many pregnancies are not explicitly planned [55, 56]. Providing up-front information about the options for safer conception may communicate the importance of preconception planning—to protect the future child and the partner. Recent data from Johannesburg (South Africa) suggest high fertility intentions at ART initiation [34], reflecting the importance of providing safer conception information at treatment initiation and in followup. In addition, decisions about conception are often dyadic. A partner (who is not attending clinic) may make decisions about having children—if his or her partner has not been educated it is impossible for them to have an informed conversation about the risks and options for safer conception. In addition, life transitions may be quick and there may be plans for pregnancy long before a next visit with a provider [57].

Expecting a patient to raise the issue of fertility plans on his or her own may be problematic. While not a theme in our data, published data suggest that women and men living with HIV hesitate to reveal fertility plans to HCWs for fear of judgment [36, 58]. It is not part of routine clinical practice to expect patients to tell providers when they are ready to discuss health behavior change (e.g., smoking, substance abuse, exercise, sexual behavior)—the onus is on the provider to actively inquire about behaviors that compromise health. Routine assessment of fertility goals and plans should be incorporated into clinical care for people living with HIV, with subsequent recommendations for safer conception or effective contraception options, depending on fertility goals. How to execute this in overburdened healthcare systems is a challenge but may require increased training in fertility intention assessment and comprehensive reproductive counseling for counselors.

Participants had learned of safer conception strategies from HCWs including artificial insemination, intercourse timed to peak fertility, sperm washing, home manual insemination, and intercourse with lubrication to avoid abrasions. The frequency with which sperm washing and artificial insemination was raised is interesting since these are some of the least accessible (geographically, economically) strategies for reducing transmission risk. Simpler risk reduction strategies such as delaying conception until the infected partner is on treatment with suppressed HIV RNA viral load, timing sex without condoms to peak fertility, circumcision for the male partner if he is uninfected, and manual insemination are likely to be more feasible. Our semistructured interview guide was not designed to probe specifically about particular techniques and it is possible that participants were more likely to recall discussions about and have faith in high-tech concepts such as sperm washing compared to behavioral modifications such as timing unprotected sex to peak fertility. In addition, patients may have received limited information, perhaps due to insufficient clinician training on this topic. The WHO guidelines for serodiscordant couples offer some safer conception recommendations, in addition, a more comprehensive guideline was recently published by the Southern African HIV Clinicians Society and will be helpful for clinicians [32, 54]. HCW training on the interpretation and application of these guidelines should be a priority for promoting comprehensive reproductive health counseling.

We found that, in this sample, male participants were eager to engage with HCWs in order to seek reproductive counseling. Prior data suggests that providers may have less insight into male reproductive intentions [31] and that men are less likely to seek advice from providers [38]. We previously published on the important role of men in conception decisions from an earlier analysis of these data [33], an observation which has been reported by others [9, 11, 12, 36, 59–61]. As reproductive counseling is integrated into HIV care, it will be crucial to increase male involvement. Interventions to engage men in contraception and family planning have been effective in several sub-Saharan African settings [61–63]. In addition, the dyadic nature of conception decisions and periconception risk behavior emphasizes the importance of a couple-oriented counseling approach when feasible [44].