February 28, 2014
David Fawcett, Ph.D., L.C.S.W., is a substance abuse expert, certified sex therapist and clinical hypnotherapist in private practice in Ft. Lauderdale, Fla.
"Are you an HIV-positive man who has sex with women? You can have the sex life you want and the family you want," begins a flyer announcing a connections mixer at PRO Men (Positive Reproduction Options for Men), an innovative program of the Bay Area Perinatal AIDS Center (BAPAC) in San Francisco. While reproductive health services have increasingly been available for HIV-positive women, men living with the virus have had far fewer services and support. As one man states in a video produced by the program, "I thought my sex life was over [and that I would] never have a chance of having a family, but that's not the case."
PRO Men is based at San Francisco General's Ward 86 and, with funding by the Macy's Foundation, is now in its second year. While the program began as a prevention initiative, its scope has expanded to encompass the reproductive rights of those living with HIV. In addition to medical care, the program provides education for patients, outreach both on the web and through professionally-produced videos and unique opportunities for support and networking through events such as a monthly support group and mixer.
The reproductive intentions of men living with HIV have been underestimated, and staff initially assumed that men who have sex with men (MSM) comprised the vast majority of men served by the clinic. However, Shannon Weber, who, under Deborah Cohan, M.D., coordinates the Perinatal HIV Hotline at the National HIV/AIDS Clinicians' Consultation Center at BAPAC, noted that a review of medical records found more than 500 HIV-positive men who have sex with women among the clinic's patients. Focus groups with this population have further revealed these numbers also include men who primarily have sex with men but who occasionally have sex with women or who would have sex with a woman in order to have a baby.
Development of the program has been driven by the findings of five focus groups as well as monthly support groups, which were initially designed to follow a specific curriculum, but which, according to Weber, quickly evolved based on the ongoing needs of the participants to address isolation, disclosure and stigma. The significance of these recurring themes reflects the complicated reality of sexuality, be it fear of disclosure, same-sex interactions or even feelings of shame related to the desire to have a child.
After years of social campaigns declaring condoms as the only solution to prevent transmission, couples interested in having a child have found themselves lacking information for other reproductive health options. BAPAC staff offer consultation for both patients and their partners to review multiple reproductive health options in which men are fully engaged as partners in family planning decisions.
Adherence is also discussed since, whether intending to have a child or not, it is vital both for the patient's health and for the protection of their partner. Staff can also work with couples to determine periods of highest fertility and suggest medical interventions such as PrEP (pre-exposure prophylaxis), if indicated, or review other options such as adoption or sperm donation.
Through collaboration with the group of men and medical staff and students, PRO Men staff developed resources that outline this information through professionally-filmed videos, along with several brochures on a variety of topics such as, "Is PrEP Right For Me? A Primer for HIV Negative Women," safer conception options for HIV-positive men (with HIV-negative women) and safer conception options for HIV-negative women (with HIV-positive men).
Reproductive options for both men and women living with HIV have long been weighed down by stigma and assumptions of both patients and providers. While this has changed more for women, the issue remains cloaked in shame and stigma for men. Weber reports that the extent of this stigma is dramatically illustrated by many men in the program who finally feel safe revealing their long-secret desire to become fathers.
The power of stigma has been mitigated for individuals not only by their involvement in PRO Men, but also by the willingness of some participants to talk publicly about themselves. They have appeared in videos, on speaker panels and even in a photograph and related story on the front page of the San Francisco Chronicle. This has a tremendous impact not only to inform others about the program but to dispel myths and stigma related to the reproductive rights of persons living with HIV.
Reproductive health and HIV creates strong feelings among providers as well. Weber hopes that this ground-breaking program will challenge assumptions both locally and nationally, and shift the conversation from risk reduction to one inclusive of reproductive possibilities. Provider resources include an algorithm to guide decisions for sexually active men and women as well as a policy statement for Ward 86, declaring that reproductive health is an integral part of primary care. This could serve as a model for other HIV services around the country.
In November, a gathering was convened and attended by 64 providers. A strategic decision was made to begin the event with a panel of consumers sharing their experiences. This effectively gave attendees permission to begin to think differently about issues such as disclosure, PrEP, the interaction between contraception and HIV, and the integration of reproductive health concerns into HIV clinical care. Weber notes that listening to what people want without judgment is a critical first step, and while the initial introduction of reproductive concerns into clinical interactions can be brief, such discussions are vital to caring for the whole person.
Perhaps the most exciting event to date was the Positive Connections Mixer, a gathering for those interested in dating, having sex or having a child. While professionals were on hand to provide valuable education and support, the most powerful feature was undoubtedly the presence of other like-minded attendees breaking the barriers of shame and stigma, and declaring the value of both themselves and their reproductive health intentions.
Macy's Foundation has provided a second year of funding which is currently underway and which will fund more support groups for HIV-positive men who have sex with women, along with the translation of materials into Spanish. Two additional videos on disclosure and adherence have been produced and will soon be available on the website.
Complete program information can be found at: http://hiv.ucsf.edu/care/perinatal/pro_men.html.
Clinicians with reproductive and sexual health questions in the context of HIV can receive 24/7 telephone consultation from the National Perinatal HIV Hotline at: www.nccc.ucsf.edu.
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