On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.100 n.6 Cape Town Jun. 2010
ISSUES IN MEDICINE
The burden of infertility among HIV-positive couples in South Africa: the available evidence
D Basu, J K Basu, G T H Ellison
Most of the 5 million HIV-positive South Africans are in the reproductive age group. The current infertility rate in this group is 15 - 20%,1 and it is likely that a substantial proportion of offspring are HIV positive. Given the implementation of highly active antiretroviral therapy (HAART), expectancy and quality of life, including reproductive aspirations, are raised. However, the prevalence of infertility among HIV-positive South Africans remains unknown.
Aim and method
We wished to determine the burden of infertility among HIV-positive (concordant and discordant) couples in South Africa (SA) so that the issue could be addressed in a safe and costeffective manner. We conducted a systematic search of research evidence on the burden of infertility among HIV-positive couples in SA, that was available on Pubmed and Google Scholar, using the following search string: [HIV OR AIDS] AND [infertil*] AND [males AND females] AND ["South Africa"]. The search also included all non-research evidence on www.google.co.za, www.iol.co.za, www.mg.co.za, and www.news24.com. All articles published in English over the past 10 years were included. Pearl-growing techniques were applied to examine whether any of the references cited in any of the relevant evidence found might also be eligible for inclusion.2
There was no research or non-research evidence on the burden of infertility among HIV-discordant and concordant couples in SA. We identified 10 items of research (2 through pearlgrowing) and 3 items of non-research evidence, respectively; 12 were qualitative studies that focused on the psychosocial aspects of such couples on their fertility intentions. Few studies addressed health care providers' and policy makers' attitudes towards providing fertility services for HIV-positive couples (Table I).
The review identified the following key findings:
HIV infection results in reduced fertility and poor pregnancy outcomes.
Reproductive aspirations of HIV-positive couples are subject to individual variation.
There is a delicate balance between HIV status and reproductive aspirations that is strongly influenced by use of HAART, health status of the individual, provider's attitude, and social and cultural norms.
The need for provision of fertility treatment to HIV-positive couples will grow.
The need for risk-reduction fertility treatment for HIV discordant couples is increasing.
Timed unprotected intercourse is a risky way to achieve conception, while assisted conception (such as sperm washing and intra-uterine insemination) are safe alternatives and may be cost-effective in the long term.
Health care providers are willing to provide fertility treatment to HIV-positive couples, although there is fear of over-expense and lack of knowledge regarding riskreduction treatment among health care managers.
Dedicated work is necessary to quantify and address the problem in a safe and cost-effective way.
Discussion and conclusion
Evidence about the prevalence of infertility among HIVpositive couples in SA is lacking. Additionally, the availability and the uptake of infertility services by HIV-positive couples in SA are unknown. Recent advances in the fertility management of HIV-positive couples are increasingly recognised as being effective in preventing transmission between discordant partners and from mother to fetus. These interventions have been well received by HIV-positive couples in developed countries.3 The International Federation of Gynaecology and Obstetrics allows the use of assisted reproductive techniques (ART) for all HIV-positive people in an equitable manner in properly selected cases, and there should not be any discrimination because of HIV status.4 Further studies are necessary to determine the relationship between HIV status and infertility and the burden of infertility among HIV-positive people in SA. Since the reproductive rights of all South Africans are enshrined in the Constitution, health services should ensure that HIV-positive couples have access not only to antiretroviral treatment but also to other reproductive health services including fertility.5
1. Basu JK. Service, training and research into infertility in public hospitals in South Africa. S Afr Med J 2007; 97(11): 1018. [ Links ]
2. Sclosser RW, Wendt O, Bhavnani S, Nail-Chiwetalu B. Use of information-seeking strategies for developing systematic reviews and engaging in evidence-based practice: the application of traditional and comprehensive pearl growing. A review. Int J Lang Commun Disord 2006; 41(5): 567-582. [ Links ]
3. Sunderam S, Hollander L, Macaluso M, et al. Safe conception for HIV discordant couples through sperm-washing: experience and perceptions of patients in Milan, Italy. Reprod Health Matters 2008; 16(31): 211-219. [ Links ]
4. FIGO. Ethical Issues in Obstetrics and Gynaecology for the Study of Ethical Aspects of Human Reproduction and Women's Health. London: FIGO, October 2009: 62-63. [ Links ]
5. Delvaux T, Nostlinger C. Reproductive choice for women and men living with HIV: contraception, abortion and fertility. Reprod Health Matters 2007; 15(29 suppl): 46-66. [ Links ]
Dr D Basu is a Public Health Medicine specialist in the Department of Community Health affiliated to Charlotte Maxeke Johannesburg Academic Hospital and the University of the Witwatersrand. Dr J Basu is a specialist in the Department of Obstetrics and Gynaecology at the same hospital. Professor G Ellison is director of the Graduate School of London Metropolitan University.
Corresponding author: D Basu (Debashis.Basu@wits.ac.za)