June 26, 2017
Some heterosexual men living with HIV assume they have to forego fatherhood and mixed-status relationships. At the same time, some providers may assume that heterosexual men living with HIV are gay. Providers can help dispel these misconceptions by having conversations about reproductive health with their patients.
In a focus group conducted at San Francisco General Hospital by Shannon Weber and Guy Vandenberg, heterosexual men living with HIV said that health care providers often assume them to be gay and therefore do not discuss reproductive health, Weber reported in a webinar sponsored by HIVE. Weber is the director of HIVE, an HIV service organization in San Francisco, Calif., and a cofounder of PleasePrEPMe.org. Vandenberg is an HIV activist who also works in clinical care at Ward 86, the HIV clinic of San Francisco General Hospital. Partly in response to the focus group results, the two now run a monthly reproductive health clinic at Ward 86.
Many men who have been diagnosed with HIV assume that they will have to forego fatherhood, Vandenberg noted. We now "have an amazing toolbox at our disposal" to ensure safe conception, he added. However, people need to know that these options exist. Even at his HIV clinic, providers don't necessarily take a good sexual health history. As a result, opportunities for conversations about reproductive desires are often missed. Providers are also unsure about how to start such talks and what legal issues may need to be considered if the patient's woman partner is included in the discussion. Laws on such meetings vary among states. Role-playing with a colleague may be helpful to become comfortable with starting conversations about reproductive health, Vandenberg advised.
When he was first diagnosed with HIV, Pete Devine recalled, he thought he would never be able to have sex with someone not living with HIV, or have children. Devine has lived with HIV since 2006. With the help of a support group at Ward 86, he learned that serodiscordant couples and reproduction were still options. He is now married to a woman who does not live with HIV. Get healthy and on treatment to avoid transmitting the virus, he advised: "Becoming undetectable changed my life." It was important to Vandenberg that his wife have a discussion with his HIV provider at the clinic, which is possible under California law.
One HIV health care provider who asks his patients about their plans for having children is Brent Sugimoto, M.D. He is a family physician at Kaiser Permanente in Oakland, Calif., one of the larger HIV clinics in the country. About 9% of the clinic's patients are heterosexual, and most of these are African American, often young men. Sugimoto says that asking about reproductive intentions sometimes prompts people to think about parenthood as a possibility. His clinic offers fertility services to help women in serodiscordant relationships conceive safely. However, these services are not covered by insurance, so few patients can take advantage of them. The clinic also does not offer sperm washing, surrogacy services for men who have sex with men (MSM) or similar assisted reproductive methods.
Questions about reproductive options also come up in pediatric and adolescent HIV care, Rana Chakraborty, M.D., noted. Chakraborty works at an HIV clinic associated with a large public hospital in Atlanta, Ga., caring for children and adolescents -- or "from the cradle to the rave," as he put it. Many of his patients were perinatally infected and are now reaching adolescence or young adulthood. Some of the young men he sees initiate discussions about pre-exposure prophylaxis (PrEP) or prevention of mother to child transmission, and some have already fathered children. But many of the young MSM have fled surrounding Southern states where they experienced trauma. Many of them live in poverty and are therefore uninterested in parenthood at this point in their lives. Given the ongoing opiate epidemic, issues around HIV and fatherhood are likely to become more prominent over the next decade, Chakraborty believes. His advice to providers: "Ask early and assume nothing."
Weber also noted that discussions about reproductive health must include the desire not to have children, not just parenthood.
Follow Barbara on Twitter: @reliabletran.
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