The majority of people living with HIV don’t want children, according to a study published in BMC Health Services Resources. But whether they do or don’t, integrating that care into HIV services can better inform and equip HIV-positive people to meet their sexual and reproductive health needs.

Researchers have known for years now that people with an undetectable viral load do not transmit HIV via sex, opening the door to a new era of family planning for people living with the virus. No longer are expensive interventions like sperm washing or intrauterine insemination necessary for mixed-status couples to safely have children. Now, “the old-fashioned way” is safe when the man has HIV and is on effective treatment, and pre-exposure prophylaxis (PrEP) adds an extra layer of protection for the woman.

For HIV-positive women in the United States, HIV treatment has nearly eliminated transmission to infants, but there are still a few cases of breakthrough perinatal transmission despite viral suppression. Data on HIV treatment during pregnancy is scant, however, and antiretrovirals have not been adequately studied or optimized for women during conception and pregnancy to improve outcomes and completely eliminate mother-to-child transmission.

Yet in South Africa, as in the United States, HIV care is often siloed from gynecological and obstetric care. In the prevention realm, most U.S. obstetricians and gynecologists who don’t specifically treat women with HIV do not offer PrEP for those wishing to conceive with a partner living with HIV. Ryan White Part D clinics do exist to serve primarily women living with HIV and their children. But in 2016, the Department of Health and Human Services only funded Part D programs in seven states, compared with 27 states that received Ryan White Part A funding, which covers HIV treatment.  

In 2010, clinicians at a public hospital and six associated clinics in the eThekwini District of KwaZulu-Natal, South Africa, started a new program in which they integrated sexual and reproductive health care into traditional HIV services and had sexual and reproductive health clinicians begin to offer HIV testing and counseling at postnatal clinics and those offering family planning services.

Before and after implementation, Cecilia Milford, PhD, a senior researcher at the University of Witwatersrand in Durban, and colleagues, surveyed 269 people who received care at HIV clinics before the new model that integrated sexual and reproductive health into HIV care and then 300 people who did so after its implementation. The vast majority were identified as women—221 at baseline and 230 after program implementation—but 70 men answered questions on the program after it was put in place. The program also added a care navigator as the systems tried to integrate HIV care and sexual and reproductive health care and created repeated opportunities for community members to guide the development and implementation of services.

The survey asked couples what they wanted from family planning care and whether they perceived themselves to be capable of having children given their HIV status. In addition, the researchers talked to 46 and 44 clinicians, respectively, before and after program integration about their comfort level regarding their clients living with HIV having children.

At baseline, 32% of all clients at all the clinics and the hospital were living with HIV, but by the end of the study, 48% were HIV positive. At the start of the program, only 13% of women said they wanted more children, while 43% of men wanted more. After the program was in place, women were far more likely to say they wanted more children: 37% of all women and 39% of women younger than 45 said they wanted more. For men, the rates remained roughly constant, with 42% of all men and 45% of men younger than 45 saying they desired a larger family.

Not many other factors influenced the desire of clients for more children—not whether they were single or married, in a steady relationship or not or if they or their partner was the one living with HIV. But a few things did register with them. Unsurprisingly, younger people were more likely to want children than older people, as were people with fewer than three children compared to those who already had more than three.

Another change was that more women who reported not wanting children were using contraception to prevent pregnancy. It’s unclear how being on HIV treatment changed a woman’s desire for children, since antiretroviral use was self-reported and they didn’t always answer the question; it was not based on a review of the clients’ charts.

When asked why they felt the way they did, none of the women interviewed after integrated care said they’d been told by a clinician not to have children, compared with one person at baseline. Given that the study was conducted before the availability of integrase inhibitors and right on the cusp of the release of information about the positive impact of early and sustained treatment on HIV outcomes and Undetectable Equals Untransmittable, or U=U, it’s not surprising that most of the reasons people gave for not wanting children were related to fears about their own health and longevity or that of their children. Between the start of the study and the end, people who didn’t want children were far less likely to say their HIV status was one of the reasons for avoiding having kids.

And while the study didn’t study the cause and effect of integrated care, Milford and colleagues said they could make some inferences. For one thing, the study shows that, with a high proportion of both women and men not wanting children, integrating HIV care and pregnancy prevention into one clinic could decrease unintended pregnancies, which have been found to be associated with a higher viral load.

Meanwhile, the number of clinicians who said they thought people with HIV should have children also shifted—in the positive direction. Fewer clinicians believed HIV-positive people shouldn’t have children.

“Whether people living with HIV want children or not, they are conceiving and therefore need access to quality information on family planning and contraceptive options,” wrote Milford and colleagues. “Those who are considering having children need counseling and support in pregnancy.”

Click here to read the full study. 

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