Multiple strategies for safer conception need to incorporate couples' preferences

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Misunderstandings about serodiscordance and limited understanding of female fertility and male insemination are barriers to couples in serodiscordant partnerships in attempting to practice safer conception methods, according to a qualitative study presented by Rebecca Phofa at the 7th South African AIDS Conference in Durban last month.

Safer conception preferences were largely influenced by an assessment of the effectiveness of the intervention at reducing or eliminating risk, concerns over side-effects of antiretroviral treatment (ART) and knowledge about the method.

Safer conception services are needed to reduce both horizontal and vertical transmission risks among serodiscordant couples trying to become pregnant. Several strategies exist to address this, including early initiation of ART for HIV-positive partners, independent of CD4 count, with viral load monitoring to confirm viral load suppression; pre-exposure prophylaxis (PrEP) for HIV-negative partners; condomless sex limited to the peri-ovulation period; or manual self-insemination using a plastic syringe if the male partner is HIV-negative.



A serodiscordant couple is one in which one partner has HIV and the other has not. Many people dislike this word as it implies disagreement or conflict. Alternative terms include mixed status, magnetic or serodifferent.


The cervix is the neck of the womb, at the top of the vagina. This tight ‘collar’ of tissue closes off the womb except during childbirth. Cancerous changes are most likely in the transformation zone where the vaginal epithelium (lining) and the lining of the womb meet.


Having sex without condoms, which used to be called ‘unprotected’ or ‘unsafe’ sex. However, it is now recognised that PrEP and U=U are effective HIV prevention tools, without condoms being required. Nonethless, PrEP and U=U do not protect against other STIs. 

focus group

A group of individuals selected and assembled by researchers to discuss and comment on a topic, based on their personal experience. A researcher asks questions and facilitates interaction between the participants.


Qualitative research is used to explore and understand people’s beliefs, experiences, attitudes or behaviours. It asks questions about how and why. Qualitative research might ask questions about why people find it hard to use HIV prevention methods. It wouldn’t ask how many people use them or collect data in the form of numbers. Qualitative research methods include interviews, focus groups and participant observation.

In-depth interviews and focus groups were held in English, Zulu and Sotho and facilitated by trained researchers using semi-structured interview guides between February and July 2013 with women and men who were in a relationship with an HIV-positive partner and were hoping to have a child in the near future.

Barriers to acceptability of PrEP for HIV-negative individuals were driven by concerns about side-effects and duration.

“People taking ARVs are only doing it because they are sick. Most fear the side effects these ARVs come with,” said a woman with HIV. “I don’t like pills because of side-effects…The syringe would be easier than taking pills every day,” said an HIV-negative man. “She must go for ARVs in the time when she tries to conceive or forever? [If just while she tries to conceive] then she could do this,” said a man with HIV.

Acceptability of manual insemination differs between HIV-positive and HIV-negative men.

“Men don’t want to be robbed of our manhood. It’s not going to be our baby, it is like it’s someone else’s [if manual insemination is used],” said a man with HIV, while an HIV-negative man stated, “I would use the syringe as long as I would get a baby and I wouldn’t get the virus. The most important thing is to have a baby and remain HIV-negative. How the baby is done is not important.”

Misunderstandings about serodiscordance were also iterated. “The child might get infected, because even though I’m [HIV-]negative, I don’t think I’m 100% negative. If I sleep with someone who is negative, I might infect that person,” stated an HIV-negative woman.

There is also a limited understanding of female fertility and male insemination, as displayed in the responses below:

“Is there a certain temperature that semen need to be to live? Because it might cool down too much before I put it in.”

“Does she need to be hot or in the mood?”

“When there is penetration, you are closer to the cervix. But how will they [semen] get there?”

Based on the study, Phofa advocated that “effective safer conception services require a strong counselling component and a comprehensive approach with multiple strategies offered to incorporate patient preference, rather than a single algorithm.”


Phofa R et al. Acceptability and preference for antiretroviral and non-antiretroviral-based HIV prevention strategies for safer conception. 7th South African AIDS Conference, June 2015, Durban, South Africa.