Determinants of Use of Safer Conception Strategies Among HIV Clients in Uganda

描述（由申请人提供）：随着艾滋病毒越来越成为一种慢性疾病，艾滋病毒/艾滋病感染者（PLHA）对生育的渴望和计划越来越突出，特别是在撒哈拉以南非洲（SSA），生育是一种强烈的文化价值观。在公立医院的妊娠涉及垂直和水平传播风险，然而，尽管为患者预防意外怀孕或一旦怀孕（例如，预防母婴传播）提供了大量资源和支持，但旨在促进更安全受孕的服务却很少。低成本更安全的受孕策略包括抗逆转录病毒治疗、定时无保护性交和人工授精，但SSA地区PLHA对降低受孕风险方法的了解、可接受性和使用情况知之甚少。艾滋病毒和计划生育（FP）提供者是公共卫生管理局生殖健康选择的重要信息和咨询来源。然而，艾滋病毒提供者经常向艾滋病毒管理局传达这样的信息：生育是不合适的，他们常常感到缺乏足够的培训，无法提供有效的安全受孕咨询，因此，当存在将病毒传播给伴侣的风险时，他们很难向患者提供咨询。类似的问题可能也存在于计划生育提供者，但这方面的研究甚至更少。因此，患者可能不舒服讨论他们的生育意图和/或怀孕与他们的提供者。这种提供者与患者之间信任和沟通的缺失，加上已经压力过大的卫生保健系统和文化信仰，导致许多公立医院向传统治疗师（TH）寻求建议，后者更容易获得，但往往没有做好充分应对艾滋病毒疾病背景的准备。迄今为止的研究主要集中在生育欲望的患病率和相关性上，很少研究使用孕前和孕后风险

DESCRIPTION (provided by applicant): With HIV becoming more of a chronic disease, desires and plans for childbearing has become increasingly prominent among persons living with HIV/AIDS (PLHA), especially in sub-Saharan Africa (SSA) where fertility is a strong cultural value. Pregnancy in PLHA involves both vertical and horizontal transmission risks, yet while there are considerable resources and support for patients to prevent unwanted pregnancy or once they become pregnant (e.g., PMTCT), services aimed at promoting safer conception are rarely available. Low cost safer conception strategies include antiretroviral therapy, timed unprotected intercourse, and manual insemination, but little known about the knowledge, acceptability and use of conception risk reduction methods among PLHA in SSA. HIV and family planning (FP) providers are a critical source of information and counseling for the reproductive health options for PLHA. Yet HIV providers often convey messages to PLHA that childbearing is inappropriate, are frequently constrained by feeling inadequately trained to offer effective counseling for safe conception, and so struggle with how to counsel patients when a risk of transmission to the partner is present. Similar issues may hold for FP providers, but this is even less studied. Consequently, patients may be uncomfortable discussing their fertility intentions and/or pregnancy with their providers. This breach in provider-patient trust and communication, coupled with an already over stressed health care system and cultural beliefs, lead many PLHA to seek advice from traditional healers (TH) who are more accessible, but often unprepared to fully address the HIV disease context. Research to date has focused on prevalence and correlates of fertility desires, with very little study of the use of pre- and post-conception risk reduction methods by PLHA. The proposed study will examine the reproductive decision making and use of conception risk reduction methods of HIV patients with fertility intentions, the knowledge, attitudes and practices of health providers regarding safer conception counseling for PLHA, and structural barriers to provision of support services. Phase 1 will be a formative evaluation of fertility planning and decision making through qualitative in-depth interviews with male and female HIV clients (and their partners) who have either recently conceived a child or have an intention to conceive; we will also interview HIV, FP and TH providers to examine knowledge, attitudes and practices related to childbearing support services for PLHA. Phase 2 will be an observational, prospective cohort study of 400 PLHA with fertility intentions who will be followed for 24 months to assess determinants of use of contraception (while waiting for the preferred time to conceive, and post-conception), pre-conception risk reduction methods, and PMTCT (when pregnant). Providers will also be surveyed longitudinally to assess changes in knowledge, attitudes, practices and structural barriers regarding provision of safer conception support over time. Findings from this study will inform the development of a structural intervention aimed at helping providers and clinics to better provide support needed by PLHA to have safer, healthy pregnancies, and limit transmission.