A separate study of men and women in sero-different couples (where one person has HIV and the other does not) has shed light on how risks and interventions are weighed up when there is a desire to have a child.
Carmel Kelly conducted in-depth, qualitative interviews with six women and four men living in Northern Ireland. Some of the participants were HIV-positive and others were HIV-negative, but each had a partner of a different HIV status. The participants were born variously in Ireland, Africa and Eastern Europe.
For each interviewee, decisions about having children could no longer be taken for granted or made without discussion with clinicians. Biomedical understandings of risk and possibilities became central to their plans for the future. In fact some participants had previously assumed that it would now be impossible to have a child, and dialogue with HIV clinicians helped many understand and believe that having a baby in the context of HIV was relatively safe and normal.
However these feelings could sometimes be challenged by distressing encounters with fertility specialists and other non-HIV clinicians who questioned a person’s aspiration to have a child.
“He [doctor] said, ‘I have to think about the protection for my nurses and the doctors and you also have to think about the protection of your wife’. Now he made me feel that I was a threat to the entire medical staff and my family. And I had gone there for help. I didn’t go there to be told, as if I was a divisive enemy or weapon.”
Participants talked about how having HIV had affected their sex lives and about wanting things to be as ‘normal’ as possible. Several of the men put a particular value on unprotected sex, which was felt to be ‘real sex’.
“I am here trying to cope with treatment, not telling people my diagnosis and now I can’t even have my wife. For how long? A night? Two months? A year? Two years? No. Forever. From now onwards sex is out of the question. I mean real sex. Now that is another prison. Another sentence.”
The women were more likely to find condoms acceptable. They were more likely to enjoy sex when they knew they were protecting their partner from HIV.
For several interviewees, the decision to have a child with their partner was a key step in their relationship and was a sign of normality for each other and for the outside world. One HIV-negative woman explained how her pregnancy would provide a distraction to community members who had suspicions about her partner’s HIV status.
Another interviewee struggled to find the English to explain how fundamental the desire to have a child was to his sense of self.
“Since then I have had that idea of having a baby because I consider myself a human being. I was someone who (my English ﬁnd it hard) to procreate. When we are healthy, when we are born and grow up we have that idea to procreate because we were procreated... But when I became HIV positive I think it is ﬁnished for me. I can’t have anymore. Having one woman, one wife and having healthy kids. These things affect me very much. When I think about it I think I am not useful anymore for people... I take the risk to do it because I want to feel as a man.”
But the same man and his wife were uncomfortable with the idea of sperm washing:
“I talk to the doctors. We discuss, they told me, they showed me the way I could have a baby without harming the baby is [sperm] washing... It is not how people want it. They want to have a baby a normal way, you know. Like my wife, when we discuss, she said, ‘no’, she can’t do this. It is better not having a baby. She born, when she born, she didn’t born that way. All babies she going to have in the future she want to have them the way she was born, normal way, you know.”
Sperm washing involves the man’s sperm being treated in a laboratory before it is artificially inseminated in his partner. The high cost of the procedure means that there can be wrangles with health bodies over payments and availability. Each attempt at a conception (of which there may be several) requires a trip to London.
Another man had considered sperm washing but expressed his preference for a pregnancy “the normal way, without any of the interventions”. It is notable that the reduction of viral load through antiretroviral treatment felt normal to him and was not perceived to be an extra intervention.
“You know they had suggested the various ways of how we could do it and we sat down and we discussed it and thought, ah well, seeing that I have been able to control the virus, and maintaining the viral load we will just do it the normal way, without any of the interventions.”
A number of participants had had unprotected sex on numerous occasions (sometimes including a period before HIV had been diagnosed), and this informed a faith or confidence they had in the possibility of having sexual relations without transmission occurring. This faith had been augmented by a growing awareness of the relevance of medication and viral load to transmission risks.
One HIV-negative woman explained how the transmission risk came to feel unexceptional to her.
“The second time [second pregnancy] it had become quite normal. You know it was not a big deal... You know, having unprotected sex with someone who is HIV-positive to become pregnant. To another person would be, like ‘what, you have done what, are you crazy?’ you know whereas to us now it’s like, you know, yeah, if you want to have another one.”
However her confidence in a low transmission risk applied only to times when she was trying for a baby; unprotected sex was not an option at other times.
Concluding her study, Carmel Kelly says that her findings demonstrate how personal priorities and meanings are central to the negotiation of risk in sexual relationships. Biomedical understandings of risk (including those based on viral load) are balanced against a broader set of expectations, meanings and desires.