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Changes in Providers’ Self-Efficacy and Intentions to Provide Safer

Conception Counseling Over 24 Months

Article  in  AIDS and Behavior · February 2018

DOI: 10.1007/s10461-018-2049-x

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 AIDS and Behavior
https://doi.org/10.1007/s10461-018-2049-x

1
ORIGINAL PAPER

2 Changes in Providers’ Self‑Efficacy and Intentions to Provide Safer

3 Conception Counseling Over 24 Months
4 Kathy Goggin1,2,10 · Emily A. Hurley1 · Glenn J. Wagner3 · Vincent Staggs1,2 · Sarah Finocchario‑Kessler4 ·
5 Jolly Beyeza‑Kashesya5,6 · Deborah Mindry7 · Josephine Birungi8 · Rhoda K. Wanyenze9

6
7 © Springer Science+Business Media, LLC, part of Springer Nature 2018

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8 Abstract
9 High rates of fertility desires, childbearing and serodiscordant partnerships among people living with HIV (PLHIV) in

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10 Uganda underscore the need to promote use of safer conception methods (SCM). Effective SCM exist but few PLHIV benefit
11 from provider-led safer conception counseling (SCC) and comprehensive national SCC guidelines are still lacking. Providers’

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12 self-efficacy, intentions and attitudes for SCC impact provision and should inform development of services, but there are no
13 longitudinal studies that assess these important constructs. This study reports on changes in providers’ knowledge, attitudes,

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14 motivation and confidence to provide SCC among a 24-month observational cohort of Ugandan HIV providers. Compared
15 to baseline, providers evidenced increased awareness of SCM, perceived greater value in providing SCC, saw all SCM but
16 sperm washing as likely to be acceptable to clients, reported consistently high interest in and peer support for providing
17 SCC, and perceived fewer barriers at the 24-month follow-up. Providers’ intentions for providing SCC stayed consistently
18 high for all SCM except manual self-insemination which decreased at 24 months. Self-efficacy for providing SCC increased
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19 from baseline with the greatest improvement in providers’ confidence in advising serodiscordant couples where the man is
20 HIV-infected. Providers consistently cite the lack of established guidelines, training, and their own reluctance to broach the
21 issue with clients as significant barriers to providing SCC. Despite providers being more interested and open to providing
22 SCC than ever, integration of SCC into standard HIV services has not happened. Concerted efforts are needed to address
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23 remaining barriers by establishing national SCC guidelines and implementing quality provider training.
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24 Keywords  HIV/AIDS · Prevention · Serodiscordant · Safer conception methods · Sexual transmission · Mother-to-child
25 transmission · Pregnancy
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6
A1 * Kathy Goggin Makerere University College of Health Sciences, Kampala, A12
A2 kgoggin@cmh.edu Uganda A13
7
1 Los Angeles Center for Culture and Health, University A14
A3 Health Services and Outcomes Research, Children’s Mercy
of California, Los Angeles, CA, USA A15
A4 Hospitals and Clinics, Kansas City, MO, USA
8
2 The AIDS Support Organization, Kampala, Uganda A16
A5 Schools of Medicine and Pharmacy, University of Missouri –
9
A6 Kansas City, Kansas City, MO, USA Department of Disease Control and Environmental Health, A17
3 Makerere University School of Public Health, Kampala, A18
A7 RAND Corporation, Santa Monica, CA, USA
Uganda A19
4
A8 Department of Family Medicine, University of Kansas, 10
Children’s Mercy Hospital Kansas City and University A20
A9 Medical Center, Kansas City, KS, USA
of Missouri – Kansas City, 2401 Gillham Road, Kansas City, A21
5
A10 Department of Obstetrics and Gynaecology, Mulago MO 64108, USA A22
A11 Hospital, Kampala, Uganda

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 AIDS and Behavior

26 Introduction The infrequent use of SCM among serodiscordant cou- 77

27 The growing global recognition of serodisordant cou-
28 ples’ childbearing desires and rights has led to calls for
29 comprehensive reproductive health services that meet cli-
30 ents’ needs while limiting risk of horizontal and vertical
31 transmission [1]. In Uganda, about 60% of people living
32 with HIV (PLHIV) wish to conceive [2, 3] and up to 50%
33 of PLHIV in relationships have an uninfected partner [4,
34 5]. Up to 40% of female PLHIV become pregnant post-
35 HIV diagnosis with about half of these pregnancies being
36 planned or desired by at least one member of the couple
37 [6]. Nevertheless, few PLHIV benefit from provider input
38 on strategies to reduce risk associated with conception
[6–8]. These high observed rates of fertility desires and
ples is unsurprising, given that services to guide couples in 78
the use of SCM are rarely available in standard HIV care. 79
Reproductive health and family planning services are com- 80
monly integrated in HIV clinics in Uganda and elsewhere in 81
sub-Saharan Africa however, they focus almost exclusively 82
on preventing unplanned pregnancies and mother-to-child- 83
transmission (PMTCT) once pregnancy occurs. Fertility 84
desires are not commonly discussed by clients and provid- 85
ers and when they are, the conversations are usually initiated 86
by the patient and rarely involve discussion of SCM [10, 18, 87
19]. Providers may be unaware of SCM, lack the necessary 88
skills to provide SCC and/or have reservations about raising 89
the topic with clients [10, 20–23]. In fact, providers have 90
historically discouraged, and thereby stigmatized, childbear-

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39 91
40 childbearing underscore the need to promote safer con- ing among HIV-affected couples [24, 25], making support- 92

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41 ception methods (SCM) for serodiscordant couples, but ive conversations uncommon. There is growing evidence 93
42 effective interventions are lacking. A thorough understand- that provider stigma toward childbearing has decreased in 94
ing of providers’ knowledge, attitudes and self-efficacy recent years [10, 20–22], however longitudinal studies of

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43 95
44 for providing safer conception counseling (SCC) is key changes in providers’ knowledge, attitudes, motivation and 96
to the development of effective services. In the context confidence to provide SCC are still lacking.

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45 97
46 of a 24-month prospective observational cohort study of Theoretically grounded studies improve the selection of 98
47 patients in Uganda [9], we followed a cohort of provid- variables to be assessed, measures to be used, interpretation 99
48 ers to examine their knowledge, attitudes and self-efficacy of results and replication of study findings [26]. As such, 100
49 for providing SCC at baseline [10] and changes in these we employed an ecological adaptation of the Information 101
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50 important variables over time. Like the patients in our Motivation and Behavioral skills (eIMB) model of behavior 102
51 cohort, we anticipated that providers’ knowledge, attitudes change in this study [27]. Our eIMB informed model posits 103
52 and self-efficacy might change over time as the general that the likelihood of providers offering SCC is influenced 104
53 awareness of SCMs and recognition of PLHIV’s childbear- by the information, motivation, and behavioral skills they 105
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54 ing desires and rights became more widespread. This is possess, as well as contextual factors in their environment. 106
55 the first longitudinal study to examine changes over time Information is necessary but not sufficient to ensure provi- 107
among these influential stakeholders. sion of SCC and includes awareness of SCM in general, 108
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56
57 Effective and low-cost SCM exist but are rarely prac- technical aspects of each method, impact on risk, risk of cur- 109
58 ticed by serodiscordant couples [11–13]. When the female rent state of unassisted pregnancies and a thorough under- 110
59 is the infected partner, manual self-insemination (MSI) standing of clients’ reasons for wanting a child. Motivation 111
eliminates all risk of transmission to her uninfected male is impacted by interest in providing SCC to the full range of
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60 112
61 partner [14]. All serodiscordant couples can reduce their potential clients (i.e., concordant couples, discordant cou- 113
62 risk by limiting unprotected sex to the three-day window ples with HIV-infected male, discordant with HIV-infected 114
63 when the female partner is most fertile, a method known as female, clients without committed partners) and the presence 115
64 timed unprotected intercourse (TUI). Though the absolute of significant perceived barriers. Behavioral skills include 116
65 risk associated with TUI is still unknown, it is thought to self-efficacy for providing SCC as well as technical expertise 117
66 be extremely low when combined with adequate adherence to identify and explain specific aspects of SCM. Contextual 118
67 to antiretroviral therapy (ART) by the HIV-infected part- factors in the sociocultural environment, the level of stigma 119
68 ner [14, 15]. Use of PrEP by the uninfected partner further toward childbearing that exists among healthcare provid- 120
69 reduces risk associated with TUI. Sperm-washing nearly ers, perceived acceptability of SCM among clients and peer 121
70 eliminates all risk of transmission from an HIV-infected support for providing SCC directly impact the availability of 122
71 male to his uninfected female partner, but it is typically too information and providers’ motivation. We did not attempt 123
72 costly for couples in low-resource settings [14, 16, 17]. In to assess the provision of SCC as widespread knowledge of 124
73 our observational cohort study described above, almost SCMs, national guidelines, provider trainings and patient 125
74 half of serodiscordant couples reported fertility desires, education tools were not available during the study. 126
75 but despite the negligible costs of MSI and TUI, only 2 This study reports longitudinal findings from a 24-month 127
76 reported using MSI and 15% reported using TUI [9]. observational cohort study of Ugandan HIV providers. We 128
assessed changes in knowledge, attitudes, motivation and 129

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 AIDS and Behavior

130 confidence to provide SCC. As this was an observational PLHIV, Perceived Value of Providing SCC, Self-Efficacy for 175
131 cohort study, no intervention was provided. Findings will Provided SCC, and three Interest in Providing SCC scales) 176
132 be used to inform the design of effective SCC services and were examined and reported in detail elsewhere [29]. In 177
133 ultimately to assist in the development of Ugandan guide- short, content validity was established via expert review 178
134 lines for the provision of these services in routine HIV care. and face validity was explored during cognitive debriefing 179
with volunteers who met study eligibility criteria. Construct 180
validity was assessed via factor analysis using ordinary least 181
135 Method squares estimation. We considered scree plots and varimax- 182
rotated matrix of factor loadings to assign items. Internal 183
136 Study Setting consistency was established with Cronbach’s Alpha. Exact 184
wording of items and response categories, as well as means 185
137 This study was conducted in collaboration with The AIDS (SD; range) for inventories, scales, and other items are pre- 186
138 Support Organization (TASO) sites in Kampala and Jinja, sented in Table 1. 187
139 Uganda. TASO is one of the largest indigenous non-govern-
mental organizations in Uganda providing comprehensive

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140 Provider Demographics and Practice Characteristics 188
141 HIV prevention, care, and support services for HIV infected
and affected Ugandans annually. TASO Kampala serves over

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142 We recorded age, sex, current position, years in practice and 189
143 6700 PLHIV and TASO Jinja cares for over 8000 patients. years worked with HIV clients. 190
TASO provides family planning and contraception services,

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144
145 but during the period of this study, no services specific to
Frequency of Childbearing Discussions 191
safer conception.

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146

We developed six items that asked providers to report on 192

147 Participants
whether they had ever discussed childbearing plans with a 193
patient (yes/no), as well as what proportion of reproductive 194
148 At baseline (May–October 2013), all medical/clinical offic-
aged female and male clients they had discussed childbear-
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195
149 ers and a convenience sample of nurses and counselors at
ing plans with in the last 30 days, and what proportion of 196
150 the two sites were approached by the study coordinator
those consultations were initiated by the female or male 197
151 and offered participation in the study. The time and day of
patient or by the provider themselves. Providers’ report of 198
152 the week in which potential participants were approached
the proportion of female and male clients with whom child-
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199
153 were varied to increase the likelihood of a diverse sample.
bearing plans had been discussed in the past month was aver- 200
154 All providers gave verbal informed consent (there were no
aged to produce a total proportion for use in analyses. 201
155 refusals), at which time we clarified that their individual
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156 responses would not be shared with TASO. Questionnaires

157 were administered via an interview conducted by study per- Provider Stigma of Childbearing Among PLHIV Scale 202

158 sonnel in English or Lugandan. Only three participants chose and Attitudes 203

to respond in Lugandan. Follow-up surveys were conducted

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159
160 at 12 and 24 months and providers received 20,000 Ush We constructed five items to gage providers’ views about 204

161 (~ $6 USD) for completing each survey. The study protocol PLHIV having children. Positively worded items were 205

162 was reviewed and approved by Institutional Review Boards reversed scored and a mean item score was computed with 206

163 at Makerere University School of Biomedical Sciences and higher scores representing more negative attitudes. In addi- 207

164 RAND Corporation, as well as the Uganda National Council tion, we asked providers four general questions about child- 208

165 for Science and Technology. bearing among PLHIV and to list their top three concerns 209
about PLHIV having children. 210

166 Measures
Awareness of SCM Inventory 211
167 Guided by the eIMB model and drawing on our own qualita-
168 tive research [21, 28] and the literature, we adapted estab- We developed seven items to assess providers’ awareness of 212
169 lished scales and constructed original items to assess the SCM. The sum of affirmative responses represented level 213
170 domains described below. Most domains are reported as of awareness of SCM. In addition, we asked providers to 214
171 single items or total scores for inventories (i.e., Awareness rate whether they had adequate information to provide SCC, 215
172 of SCM, Barriers to Providing SCC). The internal consist- if they needed training, and whether they wanted training, 216
173 ency and preliminary validity of several of the adapted and using single items and a “yes/no/not sure” response format. 217
174 original scales (i.e., Provider Stigma of Childbearing among “Not sure” responses were coded as “no” for analyses. 218

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 AIDS and Behavior

Table 1  Providers’ responses to the selected survey items and scales (completers only)

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Table 1  (continued)

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 AIDS and Behavior

Table 1  (continued)

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219 Perceived Value of Providing SCC Peer Support for Providing SCC 240

220 We developed six items to assess providers’ views of the We used two items to assess providers’ views about the 241
221 value of providing SCC. After reverse scoring all items, a receipt of peer support. A mean item score was computed 242
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222 mean item score was computed with higher scores repre- with higher scores representing greater perceived peer 243
223 senting greater perceived value. support. 244
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Interest in Providing SCC Scales 245

224 Perceived Acceptability of SCM to Clients
We constructed 12 items that formed three scales; Interest in 246
225 We adapted seven items from the WHO assessment of con- providing SCC to serodiscordant couples, Interest in provid- 247
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226 traceptive method preferences [30] to assess providers’ ing SCC regarding specific SCM, and Interest in providing 248
227 perceptions of whether clients will view specific SCM as SCC in the context of relational factors. A mean item score 249
228 acceptable. Five of the seven items were used descrip- for each scale was computed with higher scores representing 250
229 tively, and the final two on TUI and MSI were used as greater interest. 251
230 individual variables in analyses. We explored the develop-
231 ment of a scale with all seven items, but likely due to the Self‑Efficacy for Providing SCC Scale 252
232 variety of topics covered, the psychometrics were poor.
We adapted a self-efficacy measure developed by Johnson 253
et al. [31] to create eight items to assess providers’ level of 254
233 Barriers to Providing SCC Inventory confidence to discuss childbearing and provide SCC to dif- 255
ferent types of couples. A mean item score was computed 256
234 We developed 12 items to assess barriers to providing with higher scores representing greater confidence. 257
235 SCC. All items were reverse scored and a mean score
236 across items was calculated, with higher scores represent- Intentions to Provide SCC 258
237 ing a perception of the barriers being greater. Individual
238 item scores were used to compute the percentage of pro- We used five items to assess providers’ intention to provide 259
239 viders reporting some barriers (vs. no barrier at all). specific aspects of SCC. Three items were used descriptively 260

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 AIDS and Behavior

261 and two on intention to provide counseling on TUI and MSI Frequency of Childbearing Discussions with Clients 307
262 were used in the analyses. Here again, we explored the
263 development of a five-item scale, but likely due to the vari- At the 24-month assessment, all providers (100%) 308
264 ety of SCM covered, the psychometrics were poor and thus responded “Yes” to the question “Have you ever discussed 309
265 we opted to use individual items in the analyses. childbearing plans with an HIV-infected client?” as com- 310
pared to a similarly high 97% at baseline. Nevertheless, 311
266 Data Analysis on average providers had discussed childbearing with only 312
37% of reproductive aged clients in the past month, a sta- 313
267 Descriptive statistics (frequencies, means, standard devia- tistically non-significant increase from the reported 28% 314
268 tions, ranges) were used to describe sample characteristics at baseline. Discussions regarding childbearing occurred 315
269 and findings. Spearman correlations were used to examine with 49% of female and 25% of male clients, up from 316
270 associations between 24-month follow-up predictors and 36 and 20% respectively at baseline (no significant dif- 317
271 providers’ ratings of self-efficacy. ferences). When these conversations did occur, female 318
clients initiated 60%, a non-significant increase from 319
Ethical Approval the 52% observed at baseline. Conversations initiated by

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272 320
male clients significantly increased from 21% at baseline 321
The study protocol was reviewed and approved by Insti-

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273 up to 40% at the 24-month follow-up (p = 0.02). Provid- 322
274 tutional Review Boards at Makerere University School of ers reported that they initiated these discussions only 323
Biomedical Sciences and RAND Corporation, as well as 33% of the time, down from 36% observed at baseline.

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275 324
276 the Uganda National Council for Science and Technology. Providers who initiated childbearing discussions reported 325
higher awareness of SCM ­(rs = 0.49, p = 0.021), interest

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326
in providing SCC (­ r s = 0.423, p = 0.014), self-efficacy 327
277 Results ­( r s = 0.66, p < 0.001), and fewer barriers ­( r s = -0.552, 328
p < 0.001). 329
278 The baseline sample consisted of 57 providers (29 from
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279 Kampala and 28 from Jinja), including 10 medical/clinical
280 officers (6 female), 13 nurses (10 female), and 34 counselors Provider Stigma of Childbearing Among PLHIV Scale 330
281 (17 female). A total of 46 of these providers contributed data
282 to the one-year follow-up. At 24 months, responses were As displayed in Table 1, average stigma scores did not 331
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283 available from 35 providers (10 from Kampala and 25 from change significantly over time (p = 0.964) and hovered 332
284 Jinja), of whom 5 were medical/clinical officers (3 female), 6 around the midpoint of this four point scale. Most items 333
285 were nurses (5 female), and 23 were counselors (11 female). stayed about the same or got more positive, but providers 334
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286 In the second year of the study, TASO experienced a sig- endorsed more negative attitudes on two items focusing 335
287 nificant funding cut that resulted in a 40% reduction in staff on PLHIV who want children as being selfish and ensur- 336
288 positions across all sites. A complete description of the ing that all clients are having protected sex as being more 337
entire baseline sample is provided in an earlier publication important than helping couples conceive.
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289 338
290 [10]. Analyses for this study were restricted to the 35 pro-
291 viders who contributed data at baseline and 24-months. At
292 baseline, providers in this study were on average 35 years of Awareness of Safer Conception Methods 339
293 age (SD = 5.4, range 24–50 years), with just over half (57%)
294 being female and averaging 7.5 years of experience work- Overall awareness significantly improved over time 340
295 ing with clients living with HIV (SD = 3.9, range 1–25). (p < 0.001) with 100% reporting awareness of the steps 341
296 A comparison of providers who dropped out to those who required for TUI (up from 69% at baseline) and 72% 342
297 completed the 24-month evaluation revealed that dropouts displaying an understanding of MSI (baseline = 49%). 343
298 were demographically similar to completers. Dropouts evi- At 24  months, 41% of completers reported inadequate 344
299 denced similar responses to almost all variables, but were information to counsel their clients (baseline  =  45%), 345
300 slightly more likely to be interested in providing SCC to 91% reported need for more training on SC options 346
301 serodiscordant couples and had greater intentions to counsel (baseline = 100%), and 91% reported they would like to 347
302 on TUI at baseline than those who completed the 24-month receive this type of training (baseline = 100%). Providers 348
303 assessment. Changes over time for most of the questionnaire reporting awareness of comprehensive reproductive guide- 349
304 items and all items that formed scales or inventories are dis- lines (which do not exist in Uganda) dropped to 15% at 350
305 played in Table 1. Results for additional items are presented 24 months, down from 23% at baseline. 351
306 in the text below.

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352 Perceived Value of Providing SCC Scale providers’ intentions to counsel on MSI decreased over the 392
24-month follow-up period. 393
353 Providers saw increasing value over the 24-month study
354 period (p < 0.001) with less than a quarter (24%) worrying Correlates of Self‑Efficacy for the Provision of SCC 394
355 that clients would struggle to resume using condoms after at 24 months 395
356 unprotected intercourse during the fertile periods as com-
357 pared to 57% who voiced this concern at baseline. At the 24-month follow-up, providers who saw fewer bar- 396
riers (p = 0.002), had greater interest in providing SCC 397
358 Perceived Acceptability of SCM to Clients to serodisordant couples (p = 0.002), had communicated 398
with a greater proportion of clients about childbearing in 399
359 The proportion of providers agreeing that SCM would be the last 30 days (p = 0.004), reported greater peer support 400
360 acceptable to clients mostly increased over time. Except for (p = 0.01), and had fewer years of experience as a provider 401
361 sperm washing (71 vs. 82%), this proportion for all SCM (p = 0.045) reported greater self-efficacy to provide SCC 402
362 was higher at 24 months compared to baseline. (Table 2). 403

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363 Barriers to Providing SCC
Discussion

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364 Providers reported a slight yet statistically significant reduc-
tion (p < 0.006) in barriers to providing SCC at 24 months. Providers reported having childbearing discussions with

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365 405
366 Nevertheless, as compared to baseline, a greater percentage about the same proportion of clients at 24 months as they 406
of providers viewed the lack of established SCC guidelines, reported at baseline. However, a greater percentage of these

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367 407
368 lack of training, client reluctance to discuss childbearing conversations were initiated by male clients at 24-month 408
369 needs, not having enough time and their own personal reluc- follow-up as compared to baseline. Consistent with other 409
370 tance to broach the subject with clients as greater barriers at studies, this increase is likely linked to the general increased 410
371 the 24-month follow-up. awareness among clients of the availability, effectiveness 411
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and acceptability of SCM [13, 17]. It also highlights the 412
372 Peer Support for Providing SCC importance of the issue to male clients and the role that 413

373 Providers’ reports of peer support stayed consistently high Table 2  Spearman correlations at 24  months (completers only,
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374 over time (94% or greater endorsing strong peer support). N = 35)
Self-efficacy to
375 Interest in Providing SCC Scales
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provide SCC
rs (p value)
376 Similarly, providers’ interest on all subscales stayed consist-
377 ently high. Sex (female) − 0.009 (0.959)
Age − 0.307 (0.077)
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378 Self‑Efficacy for Proving SCC Scale Years worked as provider − 0.347 (0.045)
Years worked with HIV clients − 0.157 (0.375)
379 Providers’ self-efficacy significantly increased over time Proportion of patients communicated with about 0.485 (0.004)
childbearing in last 30 days
380 (p = 0.022) with the greatest improvements observed in pro-
Provider stigma of childbearing scale − 0.178 (0.314)
381 viders’ confidence in advising serodiscordant couples where
Awareness of SCM 0.151 (0.394)
382 the man is infected, when disclosure had not happened, or
Perceived value of providing SCC scale 0.299 (0.086)
383 with clients who did not have a committed partner.
Perceived acceptability of TUI − 0.030 (0.87)
Perceived acceptability of MSI 0.050 (0.78)
384 Intentions to Provide SCC
Barriers to providing SCC − 0.504 (0.002)
Peer support for providing SCC 0.435 (0.01)
385 Providers’ intentions to talk to clients about childbearing
Interest in providing SCC
386 desires, share the availability of SCM, and counsel on TUI
 To serodiscordant couples scale 0.518 (0.002)
387 and MSI were all high at baseline (all averaged 7 or better
 Regarding Specific SCM scale − 0.011 (0.95)
388 on 10 point scale). Changes over time were generally small
 In context of relational factors scale − 0.038 (0.831)
389 and mixed. Providers’ intentions to talk to male and female
Intentions to counsel on TUI 0.277 (0.112)
390 clients about childbearing desires, discuss the availability
Intentions to counsel on MSI − 0.039 (0.828)
391 of SCM and counsel on TUI fluctuated slightly. However,

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 AIDS and Behavior

414 they can play in safer conception. Consistent with baseline, issue with clients as significant barriers. Provision of high 467
415 providers reported initiating these conversations about a quality training that addresses providers’ own reservations 468
416 third of the time. This lack of change indicates that rates about SCC is needed to improve reproductive services for 469
417 of provider-initiated support for childbearing discussions is all clients living with HIV. Collaboration with the Min- 470
418 not likely to increase without a dedicated effort to address istry of Health to address the lack of national guidelines 471
419 providers concerns and training needs. Providers who initi- is also needed to ensure the regular provision of these 472
420 ate childbearing discussions reported greater awareness of needed services. The Uganda National Strategic Plan and 473
421 SCM, interest in and self-efficacy for providing SCC and National Priority Action Plan for HIV/AIDS states that a 474
422 saw fewer barriers for the provision of SCC. Providing high key intervention to reduce HIV transmission is the inte- 475
423 quality training that promotes increases in these important gration of sexual and reproductive health into HIV care 476
424 constructs among providers who are not currently initiating programs [34]. Nevertheless, the current versions provide 477
425 childbearing conversations with their clients might greatly only very minimal guidance on how to support couples 478
426 improve the rate of childbearing discussion occurring in with childbearing desires. 479
427 clinical care. Providers’ intentions stayed consistently high especially 480
In general, providers’ endorsement of negative stigmatiz- given the lack of training and support for SCC. The only

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428 481
429 ing attitudes towards clients who desire a child stayed the noticeable change was a reduction in their intention to coun- 482
same or slightly improved. Nevertheless, increases in the sel on MSI. This is congruent with their consistent report of

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430 483
431 proportion of providers who view clients with childbear- concern that this method will not be acceptable to clients. 484
ing desires as selfish or see promoting safer sex as more Although the high cost of sperm washing puts it out of reach

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432 485
433 important than safer conception counseling reveal that there for almost all clients, MSI was seen as the least acceptable 486
are lingering negative attitudes that may negatively impact SCM to clients at all time points. As suggested by other

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434 487
435 care provision. Consistent with the eIMB model, education research [35], the perceived acceptability of MSI is likely to 488
436 on the availability of effective SCM alone will likely not improve following high quality education and training that 489
437 impact these provider attitudes. Rather, effective training includes reports of real couples’ successful use. 490
438 will need to employ strategies to guide providers in explor- Self-efficacy for providing SCC increased from baseline 491
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439 ing their own underlying reasons for holding these negative with the greatest improvement in providers’ confidence in 492
440 attitudes. Increasing providers’ understanding of and empa- advising serodiscordant couples where the man is HIV- 493
441 thy for clients while providing a more realistic understand- infected. This is likely because providers are more comfort- 494
442 ing of the risks involved in assisting couples versus doing able with TUI which is the only viable option for these cou- 495
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443 nothing will be necessary [28, 32]. Exposing providers to ples. In contrast, a more modest increase was observed for 496
444 findings from our pilot intervention studies, where we found serodiscordant couples where the woman is HIV-infected. 497
445 that 40% of couples provided with unbiased SCC chose not This is likely because providers view this situation as more 498
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446 to pursue conception and where we observed no seroconver- complicated because MSI is the best option but they feel 499
447 sions among discordant couples [21], might help providers less comfortable with it. Despite removing all risk for the 500
448 who fear doing harm by providing SCC. Guiding providers HIV-infected male partner, MSI is still seen by providers as 501
to shift their focus from feeling responsible for potentially unlikely to be acceptable to clients and they therefore antici-
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449 502
450 negative outcomes to their role in assisting clients in making pate having to offer TUI, which introduces risk for the unin- 503
451 their own informed decisions will be critical. Facilitating fected male partner. Not surprisingly, without training and 504
452 the sharing of success stories through provider and client support, providers are likely to be more ambivalent about 505
453 testimonials will also likely help to further reduce stigma offering SCC to serodiscordant couples where the woman 506
454 and reinforce the importance of providers’ role. is HIV-infected. 507
455 Compared to baseline, providers evidenced increased Correlates of greater self-efficacy at 24 months included 508
456 awareness of SCM, perceived greater value in providing greater interest in providing SCC to serodiscordant cou- 509
457 SCC, saw all but sperm washing as likely to be acceptable ples and availability of peer support, as well as perceiving 510
458 to clients, reported consistently high peer support for and fewer barriers, having engaged in a greater proportion of 511
459 interest in providing SCC, and reported fewer barriers at childbearing discussion in the last 30 days, and having less 512
460 the 24-month follow-up. As this is the first longitudinal years of experience as a provider. These important correlates 513
461 study, these are the first data to demonstrate improvements of provider self-efficacy are not likely to improve to levels 514
462 in these important constructs over time. Changes are likely where SCC can become a part of normal practice without a 515
463 related to increasing general awareness of SCM and rec- dedicated effort to develop and test a comprehensive repro- 516
464 ognition of reproductive rights of PLHIV [22, 33]. Impor- ductive health program that includes high quality training 517
465 tantly, providers still see the lack of established guidelines, which addresses providers’ ambivalence about providing 518
466 inadequate training, and their own reluctance to broach the SCC to all of their clients living with HIV. 519

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520 Limitations References 568

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561 Acknowledgements  The authors acknowledge the important contribu- Ugandan HIV-affected couples with fertility intentions. AIDS 625
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567 have no disclosures. Mendoza C, et al. Natural pregnancies in HIV-serodiscordant 631

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