By: Blair Freed
Editor’s Note: To mark National HIV Testing Day today, we are highlighting research related to people living with HIV and their fertility planning strategies. Blair Freed, a resident and former FACTS elective participant, summarized a 2021 article published by Zia Y, Velloza J, Oluoch, et al. in Reproductive Health that examined cycles of 65 women in HIV-serodifferent couples from Kenya.
Introduction
Kenya is reported to have the third-largest incidence of HIV in the world — with 1.4 million people reportedly living with HIV in 2020 and a 4.2% prevalence in individuals ages 15 to 49 [1]. An HIV-serodifferent relationship refers to a couple where one partner is HIV-positive, while the other is not. In Africa, it is estimated that two-thirds of individuals who are HIV-positive and in a relationship are with a partner who is HIV negative. In these serodifferent relationships, HIV-positive status for one of the partners in a relationship warrants considerations of strategies for successful conception while attempting to lower the risk of HIV transmission as much as possible.
In cases of HIV-serodifferent partners seeking to achieve pregnancy, lowering risk of HIV transmission necessitates timing condomless acts of intercourse with knowledge of peak fertility. In such instances, fertility awareness-based methods (FABMs) can be a valuable resource for predicting peak fertility and maximizing timing of non-protected intercourse to optimize chances of conception. FABMs may utilize cervical mucus monitoring, basal body temperature measurements, menstrual cycle tracking, and/or use of ovulation predictor kits to identify the potential window of fertility. There is relatively little data showing use of these parameters in HIV-serodifferent couples to align intercourse and known times of fertility.
Methodology
Zia Y, Velloza J, Oluoch, et al. conducted an open-label pilot study with data from 74 HIV-serodifferent heterosexual couples in Thika, Kenya who were seeking pregnancy [2]. The duration of the study was from March 2016 through April 2018. The evaluation stemmed from the Safer Conception Intervention for Partners and had eligibility criteria that necessitated the couples currently being sexually active and seeking pregnancy, access to a cellular device for SMS, and no underlying or previous indications of infertility.
As part of the Safer Conception Intervention for Partners, couples were offered the following medications and resources: antiretroviral therapy, daily pre-exposure prophylaxis, condoms at every visit, testing and treatment for sexually transmitted infections, and counseling and education regarding FABMs. In addition, couples were offered referrals for self-insemination, reproductive services, male-circumcision for men not affected by HIV and sperm washing. FABM education included ovulation prediction kits, basal body temperature measurements, education about menstrual cycle and cervical mucus monitoring, and how to track the information on a chart.
Information was collected via mobile SMS on parameters including: cervical mucus, menstrual bleeding, intercourse, cervical mucus quality, and use of condoms. Information gathered was used to calculate peak fertility days and provided to participants. Intercourse was classified according to whether condomless sex occurred within peak day parameters, outside of peak parameters, or partially within peak parameters. Multinomial logit models were used to evaluate alignment of condomless intercourse to sexual activity to data provided regarding peak days of fertility. Cox proportional hazards with Andersen-Gill extension were used to evaluate pregnancy.
Results
The data included over 6,000 SMS surveys over more than 250 menstrual cycles. Women were HIV-positive in 47% of the relationships. There were no documented HIV transmission events throughout the study. A total of 31 pregnancies occurred during the study. Of the 74 initial couples, 65 were included in the final analysis; the others were excluded based on becoming pregnant before participating in data collection, not responding to SMS, or having unidentifiable peak fertility.
The data demonstrated that 71% of participants aligned condomless intercourse in greater than or equal to one cycle during peak fertility. There was an increase in use and compliance of FABMs in this population. Overall, a large number of women reported condomless sex when they were outside the fertility period (both aligned and partially aligned). For those with aligned cycles, the rate was 0.5 pregnancies per year. For those with partially aligned cycles, the pregnancy rate was 1.62. For those with not aligned cycles, the pregnancy rate was 1.55.
Discussion
This article is significant because it addresses the use of FABMs in HIV-serodifferent couples in a global health setting. With relatively little data on this population to date, this research represents an important step in the globalization of education and implementation of these methods. The results demonstrated that simply educating couples on the use of FABMs is associated with an increase in use of these methods. This in itself speaks to the compliance and use of participants when they receive education about FABMs and the opportunity to use them.
“Simply educating couples on the use of FABMs is associated with an increase in use of these methods.”
It is important, however, to address the results indicating a lower pregnancy incidence in the aligned category of condomless intercourse during peak days. Historical data on FABMs shows that, with correct use, they are highly effective in improving fertility rates [3]. The results in this study thus raise questions about true identification of peak days, reporting of intercourse, and ability of participants to correctly apply the FABM. Participant visits with the researchers were not in conjunction with menstrual cycles and thus follow up, communication, and level of understanding of the methods may have played a role, and presents an important point for further research studies.
Many questions remain to explore in the future. How can barriers to education and implementation be addressed in a global health setting? Was translation of the educational materials provided part of the issue? Was the education accomplished through use of a translator or was it provided directly in their native language? Closer examination of potential language barriers and FABM teaching methods may be an important factor in future research studies. Giventhe high reports of method use among participants, the issue may stem not from compliance but from issues with implementation.
A real strength of this study was the use of SMS technology. Follow-up meetings could not always coincide with menstrual cycles, and daily texting provided efficiency and communication to the study.However, this ease of communication also presents a limiting factor challenge for similar studies that may not have access to that technology.
Overall, the study is a testament to the power of FABMs among an understudied population when given the education and opportunity to use these methods. Importantly, it sets a precedent as well as raises future research questions for similar studies in the future.
References
[1] Avert. (2020, August 25). HIV and AIDS in Kenya. Avert. Retrieved September 13, 2021, from https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/kenya.
[2] Zia Y, Velloza J, Oluoch L, et al. Use of fertility awareness methods as a component of safer conception for women in HIV-serodifferent relationships in Kenya. Reprod Health. 2021;18(73). https://doi.org/10.1186/s12978-021-01128-5.
[3] Mu Q, Fehring RJ. Efficacy of achieving pregnancy with fertility-focused intercourse: MCN. Am J Matern/Child Nurs. 2014;39:35–40. https://doi.org/10.1097/NMC.0b013e3182a76b88.
ABOUT THE AUTHOR
Blair Freed, DO
Blair Freed, DO is a 2022 graduate of Kansas City University with a degree in Osteopathic Medicine. She is a resident in Obstetrics and Gynecology at St. Joseph Mercy Oakland in Pontiac, Michigan. Blair is interested in patient advocacy, social determinants of health, and women’s health in global settings. She participated in both sections of the FACTS elective in 2021.
Inspired by what you read?
You can support the ongoing work of FACTS here. To connect with a member of our team, please email development@FACTSaboutFertility.org. Interested in becoming an individual or organizational member? You can learn more and register here. To discuss with a member of our team, please email membership@FACTSaboutFertility.org.
