Mixed status couples prefer combination HIV protection in Kenya
High uptake of combination HIV prevention strategies among mixed-status couples in Kenya, offers new insights into the acceptability of services.
Mixed status couples – where one partner is living with HIV and the other is not – preferred to use a combination of HIV prevention strategies to safely conceive a child, with the most popular being antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP), and voluntary male medical circumcision (VMMC).
In this study from Kenya, researchers attempted to bridge the knowledge gap around safer conception options among both individuals and healthcare providers and help start the discussion about these methods (individually and as a package).
These ‘safer conception’ strategies can include: the use of antiretroviral therapy (ART) for the partner living with HIV, pre-exposure prophylaxis (PrEP) for the HIV-negative partner, testing and treatment of sexually transmitted infections (STI), voluntary medical male circumcision (VMMC), restricting condomless sex to peak fertility days, fertility screening to rule out subfertility, vaginal self-insemination when the woman is living with HIV, and/or the use of fertility technologies, such as sperm washing when the male partner is living with HIV.
In this open-label pilot study, researchers provided the Safer Conception Intervention for Partners (SCIP) to 74 mixed status couples wanting to conceive. 54% of the couples were female HIV-negative/ male HIV-positive couples. The median age of the women was 29.8 years and 35.3 years for the men. Approximately one-third (31.1%) already had children together and 87% wanted a child in the next year.
Over the course of one year, the couples received regular HIV testing and counselling, were informed, counselled and provided with PrEP if they wanted it. HIV-positive partners had their viral load and CD4 counts monitored every three months until they reached viral suppression, and then every six months thereafter. At every monthly visit, patients were tested for gonorrhoea, chlamydia and trichomonas, and treated as per national guidelines. Referrals were provided to male partners desiring VMMC and to men and women for fertility care when sperm washing or another assisted reproductive service was desired. Adverse events and social harms were also monitored, and a psychologist was engaged to provide services for mental health and gender-based violence.
The intervention was enhanced by multiple mobile health (mhealth) interventions. These included a six-item daily pre-pregnancy SMS survey completed by women to capture daily fertility indicators and sexual behaviour; weekly SMS messages to men and women reminding them of peak fertility days during peri-conception periods. In addition to this, clinics used an application on tablets to track fertility, PrEP and viral load data, which was used to inform counselling sessions.
Over the course of the intervention, 54% of the couples became pregnant with no new HIV infections – this was statistically significant when compared to authors’ original estimates of HIV infections. Uptake of the intervention was high, with 96.6% having at least one study visit, and 77% being actively enrolled during the study.
Most (95.7%) pregnancies were protected by two or more strategies: 57.4% were protected by high PrEP and ART adherence, combined with male circumcision with or without timed condomless sex; 21.3% were protected by viral suppression in the HIV-positive partner combined with male circumcision with or without timing condomless sex; and 17.0% were protected by high PrEP adherence combined with male circumcision with or without timing condomless sex.
In their conclusion, the authors noted, “Providing couples with multiple preventions options was important as not one intervention was used 100% of the time leading up to pregnancy. Importantly, there was not 100% HIV viral suppression leading up to all pregnancies and during the months of pregnancy attempts.”