Subfertility among HIV-Affected Couples in a Safer Conception Cohort in South Africa.

BACKGROUND: Subfertility among couples affected by HIV impacts on the wellbeing of couples who desire to have children and may prolong HIV exposure. Subfertility in the antiretroviral therapy era and its determinants have not yet been well characterized.

OBJECTIVES: To investigate the burden and determinants of subfertility among HIV-affected couples seeking safer conception services in South Africa.

STUDY DESIGN: Non-pregnant women and male partners in HIV seroconcordant or HIV discordant relationships desiring a child were enrolled in the Sakh'umndeni safer conception cohort at Witkoppen Clinic in Johannesburg between July 2013─April 2017. Clients were followed prospectively through pregnancy (if they conceived) or until six months of attempted conception, after which they were referred for infertility services. Subfertility was defined as not having conceived within 6 months of attempted conception. Robust Poisson regression was used to assess the association between baseline characteristics and subfertility outcomes; inverse probability weighting (IPW) was used to account for missing data from women lost-to-safer conception care before 6-months of attempted conception.

RESULTS: Among 334 couples enrolled, 65% (IPW-weighted, 95% CI: 0.59-0.73) experienced subfertility, of which 33% were primary subfertility and 67% secondary subfertility. Compared to HIV-negative women, HIV-positive women not on antiretroviral therapy had a two-fold increased risk of subfertility (weighted and adjusted [w-aRR 2.00; 95% CI: 1.19-3.34). Infertility risk was attenuated in women on antiretroviral therapy but remained elevated even after ≥2 years on antiretroviral therapy (w-aRR 1.63; 95% CI: 0.98-2.69). Other factors associated with subfertility were female age (w-aRR 1.03, 95% CI 1.01-1.05 per year), male HIV-positive status (w-aRR 1.31; 95% CI: 1.02-1.68), male smoking (w-aRR 1.29; 95% CI: 1.05-1.60) and trying to conceive for ≥1 year (w-aRR 1.38; 95% CI: 1.13-1.68).

CONCLUSIONS: Two in three HIV-affected couples experienced subfertility. HIV-positive women were at increased risk of infertility, even when on antiretroviral therapy. Both male and female HIV status were associated with subfertility. Sub-fertility is an underrecognized reproductive health problem in resource limited settings and may contribute to prolonged HIV exposure and transmission within couples. Low cost approaches for screening and treating subfertility is this population are needed.