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1.  Challenges with couples, serodiscordance and HIV disclosure: healthcare provider perspectives on delivering safer conception services for HIV-affected couples, South Africa 
Introduction
Introduction Safer conception interventions should ideally involve both members of an HIV-affected couple. With serodiscordant couples, healthcare providers will need to manage periconception risk behaviour as well tailor safer conception strategies according to available resources and the HIV status of each partner. Prior to widespread implementation of safer conception services, it is crucial to better understand provider perspectives regarding provision of care since they will be pivotal to the successful delivery of safer conception. This paper reports on findings from a qualitative study exploring the viewpoints and experiences of doctors, nurses, and lay counsellors on safer conception care in a rural and in an urban setting in Durban, South Africa.
Methods
We conducted six semistructured individual interviews per site (a total of 12 interviews) as well as a focus group discussion at each clinic site (a total of 13 additional participants). All interviews were coded in Atlas.ti using a grounded theory approach to develop codes and to identify core themes and subthemes in the data.
Results
Managing the clinical and relationship complexities related to serodiscordant couples wishing to conceive was flagged as a concern by all categories of health providers. Providers added that, in the HIV clinical setting, they often found it difficult to balance their professional priorities, to maintain the health of their clients, and to ensure that partners were not exposed to unnecessary risk, while still supporting their clients’ desires to have a child. Many providers expressed concern over issues related to disclosure of HIV status between partners, particularly when managing couples where one partner was not aware of the other's status and expressed the desire for a child. Provider experiences were that female clients most often sought out care, and it was difficult to reach the male partner to include him in the consultation.
Conclusions
Providers require support in dealing with HIV disclosure issues and in becoming more confident in dealing with couples and serodiscordance. Prior to implementing safer conception programmes, focused training is needed for healthcare professionals to address some of the ethical and relationship issues that are critical in the context of safer conception care.
doi:10.7448/IAS.17.1.18832
PMCID: PMC3956311  PMID: 24629843
safer conception; couples; serodiscordance; healthcare providers
2.  Double Disclosure Bind: Complexities of communicating an HIV diagnosis in the context of unintended pregnancy in Durban, South Africa 
AIDS and behavior  2014;18(0 1):10.1007/s10461-013-0521-1.
doi:10.1007/s10461-013-0521-1
PMCID: PMC3823675  PMID: 23722975
PMTCT; HIV Disclosure; unintended pregnancy; South Africa
3.  South Africans with recent pregnancy rarely know partner’s HIV serostatus: implications for serodiscordant couples interventions 
BMC Public Health  2014;14(1):843.
Background
Implementation of safer conception strategies requires knowledge of partner HIV-serostatus. We recruited women and men in a high HIV-prevalence setting for a study to assess periconception risk behavior among individuals reporting HIV-serodiscordant partnerships. We report screening data from that study with the objective of estimating the proportion of individuals who are aware that they are in an HIV-serodiscordant relationship at the time of conception.
Methods
We screened women and men attending antenatal and antiretroviral clinics in Durban, South Africa for enrollment in a study of periconception risk behavior among individuals with serodiscordant partners. Screening questionnaires assessed for study eligibility including age 18–45 years (for women) or at least 18 years of age (for men), pregnancy in past year (women) or partner pregnancy in the past 3 years (men), HIV status of partner for recent pregnancy, participant’s HIV status, and infected partner’s HIV status having been known before the referent pregnancy.
Results
Among 2620 women screened, 2344 (90%) met age and pregnancy criteria and knew who fathered the referent pregnancy. Among those women, 963 (41%) did not know the pregnancy partner’s HIV serostatus at time of screening. Only 92 (4%) reported knowing of a serodiscordant partnership prior to pregnancy. Among 1166 men screened, 225 (19%) met age and pregnancy criteria. Among those men, 71 (32%) did not know the pregnancy partner’s HIV status and only 30 (13%) reported knowing of a serodiscordant partnership prior to pregnancy.
Conclusions
In an HIV-endemic setting, awareness of partner HIV serostatus is rare. Innovative strategies to increase HIV testing and disclosure are required to facilitate HIV prevention interventions for serodiscordant couples.
doi:10.1186/1471-2458-14-843
PMCID: PMC4246447  PMID: 25124267
HIV prevention; HIV serodiscordant couples; Safer conception; HIV serostatus disclosure
4.  A conceptual framework for understanding HIV risk behavior in the context of supporting fertility goals among HIV-serodiscordant couples 
Reproductive health matters  2012;20(39 Suppl):50-60.
Integrated reproductive health services for people living with HIV must address their fertility intentions. For HIV-serodiscordant couples who want to conceive, attempted conception confers a substantial risk of HIV transmission to the uninfected partner. Behavioral and pharmacologic strategies may reduce HIV transmission risk among HIV-serodiscordant couples who seek to conceive. In order to develop effective pharmaco-behavioral programs, it is important to understand and address the contexts surrounding reproductive decision-making; perceived periconception HIV transmission risk; and periconception risk behaviors. We present a conceptual framework to describe the dynamics involved in periconception HIV risk behaviors in a South African setting. We adapt the Information-Motivation-Behavioral Skill Model of HIV Preventative Behavior to address the structural, individual and couple-level determinants of safer conception behavior. The framework is intended to identify factors that influence periconception HIV risk behavior among serodiscordant couples, and therefore to guide design and implementation of integrated and effective HIV, reproductive health and family planning services that support reproductive decision-making.
doi:10.1016/S0968-8080(12)39639-0
PMCID: PMC3608509  PMID: 23177680
conceptual framework; HIV; serodiscordant couples; pregnancy; safer conception
5.  A retrospective study of Human Immunodeficiency Virus transmission, mortality and loss to follow-up among infants in the first 18 months of life in a prevention of mother-to-child transmission programme in an urban hospital in KwaZulu-Natal, South Africa 
BMC Pediatrics  2012;12:146.
Background
Follow up of Human Immunodeficiency Virus (HIV)-exposed infants is an important component of Prevention of Mother-to-Child Transmission (PMTCT) programmes in order to ascertain infant outcomes post delivery. We determined HIV transmission, mortality and loss to follow-up (LTFU) of HIV-exposed infants attending a postnatal clinic in an urban hospital in Durban, South Africa.
Methods
We conducted a retrospective cohort study of infants born to women in the PMTCT programme at McCord Hospital, where mothers paid a fee for service. Data were abstracted from patient records for live-born infants delivered between 1 May 2008 and 31 May 2009. The infants’ LTFU status and age was based on the date of the last visit. HIV transmission was calculated as a proportion of infants followed and tested at six weeks. Mortality rates were analyzed using Kaplan-Meier (K-M), with censoring on 15 January 2010, LTFU or death.
Results
Of 260 infants, 155 (59.6%) remained in care at McCord beyond 28 weeks: one died at < 28 days, three died between one to six months; 34 were LTFU within seven days, 60 were LTFU by six months. K-M mortality rate: 1.7% at six months (95% confidence interval (CI): 0.6% to 4.3%). Of 220 (83%) infants tested for HIV at six weeks, six (2.7%, 95% CI: 1.1% to 5.8%) were HIV-infected. In Cox regression analysis, late antenatal attendance (≥ 28 weeks gestation) relative to attending in the first trimester was a predictor for infant LTFU (adjusted hazards ratio = 2.3; 95% CI: 1.0 to 5.1; p = 0.044).
Conclusion
This urban PMTCT programme achieved low transmission rates at six weeks, but LTFU in the first six months limited our ability to examine HIV transmission up to 18 months and determinants of mortality. The LTFU of infants born to women who attended antenatal care at 28 weeks gestation or later emphasizes the need to identify late antenatal attendees for follow up care to educate and support them regarding the importance of follow up care for themselves and their infants.
doi:10.1186/1471-2431-12-146
PMCID: PMC3468389  PMID: 22963527
HIV-exposed infants; LTFU; Prevention-of-Mother-to-Child Transmission; Postnatal clinic

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