Integrating Reproductive Health into the Primary HIV Care Setting: A Guide Informed by Experiences with the PRO Men Program

We created this toolkit for providers of men living with HIV, to support your patients in achieving their sexual and reproductive health goals.

We are at an incredible time of promise in the HIV epidemic with the knowledge needed to eliminate sexual HIV transmission. The PRO Men (Positive Reproductive Outcomes for HIV+ Men) approach provides a unique opportunity to serve men living with HIV and reach their HIV-negative female partners. The PRO Men model for integrating sexual and reproductive health care into the primary care setting represents an opportunity to reframe the story from one of risk reduction and permission to a story of possibility, hope, and risk elimination.

 

“I attended the very first PRO Men group that Shannon and Guy co-facilitated which was, basically, a support group at the time for straight and bi men who wanted to have sex with women. It wasn’t until this time with my newly undetectable viral load status that I seriously began to have confidence over the issue of having sex and dating and having possible relationships with women and the strength to disclose to them. Becoming undetectable totally changed my life, it’s a game changer…” — Pete Devine, PRO Men participant.

Background: Repro Health for Men Living with HIV

The number of male-female HIV serodifferent couples of reproductive age who live in the U.S. is between 120,773 and 257,640 (NHPS 2015). An estimated 50-70% of men living with HIV (who have sex with women) in the United States have HIV-negative female sexual partners. Many couples are in need of HIV prevention, family planning and safer conception services. In a 2001 national survey of adults living with HIV in the United States, 28% of heterosexual or bisexual men desired children, and of these, 59% expected to have a child in the future. A more recent survey of men and women living with HIV in Los Angeles County clinics reported fertility desires among men at 39%.

Additionally, in San Francisco focus groups conducted with men living with HIV who have sex with women, many men expressed the desire to have a child, yet most reported their providers had not discussed reproduction with them. Participants conveyed limited awareness of safer conception strategies. They also highlighted the lack of HIV services for men who have sex with women and the need for improved reproductive counseling.

PRO Men was launched by HIVE in 2012 and was aimed at the ~500 men who have sex with women who received care at Zuckerberg San Francisco General’s (ZSFG) Ward 86. In 2013, the initiative expanded to the ZSFG Family HIV Clinic. The PRO Men initiative aimed to:

  • Engage men to determine their reproductive health intentions.
  • Support clinicians integrating reproductive health care into the primary care setting.
  • Offer biomedical HIV prevention options for female partners of men living with HIV, such as pre-exposure prophylaxis (PrEP) and Treatment as Prevention (TasP), as well as offer safer conception and contraceptive counseling.

The PRO Men cohort was a diverse group of men with varying life experiences, including: heterosexual-identified and bisexual-identified men; men who inject drugs; men who have sex with men for money, drugs, or to meet other needs; men who have sex with men who have children from previous relationships; and men who have sex with men and want to have babies via sex with a woman.

The PRO Men Story: A Flow Chart

A visual depiction of the PRO Men development process:

 

Lessons Learned

  • Support groups served as a way to normalize experiences among men who felt isolated and stigmatized.
  • Men felt discomfort around disclosure of their sexual orientation and history to clinicians and others.
  • Many expressed a sense of isolation and stigma.
  • The clinic assessment and Electronic Medical Record lacked documentation of sexual history and sexual orientation.
  • Some clinicians felt discomfort discussing their patients’ sexual histories.
  • Advertising support groups provided a great way to engage men in accessing one-on-one counseling.
  • Many patients had never been asked if they have children. For those with little or no contact with their children, this adversely affected their self-esteem and quality of life.

 

Shifting Clinical Practice
Preparing staff:
  • Identify a point person (or people) to lead the inclusion of reproductive care for men living with HIV into your clinic. These “champions” will be instrumental in supporting clinic staff as you roll out changes.
  • You may find that there is a lack of documentation of sexual history and sexual orientation in the Electronic Medical Record. Create a “patient registry” – a list of appropriate patient to participate in your programming or intervention.
  • Identify prospective participants  by talking with providers about their patients.
  • Ensure all staff know to refer men who have sex with women to the clinic champions.
  • Make it standard practice to ask about reproductive desires.
  • Add Procreative Counseling to the problem-list (ICD-10 code: Z31.61) for all identified patients.
In clinic visits:
  • Providers should ask about current reproductive desires/intentions at baseline and annually.
  • Ask about patient’s past sexual history and if they have any children.
  • Clinicians who tend not to ask reproductive health questions, or who feel uncomfortable doing so, should be supported through trainings, role playing, etc., to incorporate sexual and reproductive health conversations into their visits.
Challenges:
  • Institutional challenges can include:
    • Limited time during patient appointments.
    • Rigid clinical documentation templates.
    • Clinic-culture not being responsive to men who have sex with women.
  • Personal challenges can include:
    • Lack of guidance on how to be most effective with limited appointment time.
    • Convincing colleagues of the importance of integrating reproductive health into their clinical practice.
    • Whether to focus on changing clinic policies or individual attitudes.

What are realistic expectations given your setting, your clinic champions’ availability and your patient population? It’s important to remember that mastery is not achieved overnight. There will be trial and error, but there will be growth.

Food for thought:
  • It’s never too late to initiate a reproductive health conversation with a patient.
  • Case managers, social workers, triage nurses, and others can support in asking about reproductive health desires.
  • Consider leading provider trainings with a consumer panel to center your work on your patients’ lived experiences.
  • See institutional barriers as opportunities.
  • Seek mentorship and/or clinical supervision during this process. Especially seek mentorship in areas that are sensitive or difficult and wrought with stigma and discrimination such as sexuality, HIV, and fatherhood/parenthood.
  • Advocate for your patients. Support patients in advocating for themselves.
  • Document your experiences. Document in a way that allows you to track qualitative and quantitative data, and then share results with your team.
Revising Clinic Policy

All patients, regardless of gender or sexual orientation, should receive a reproductive and sexual health assessment as part of their initial and annual intake. Area to assess include:

  • Desire to have children
  • If sexually active with a female partner, ask about use of contraception and attempts at conception.
  • If sexually active with a female partner, assess level of knowledge regarding contraceptive and/or safer conception options.
  • For patients with uteruses: at every visit, medical assistants should inquire about last menstrual period while obtaining vital signs.

The following should also be included as part of the annual health care maintenance assessment:

  • Current family and relationship status.
  • HIV, Hepatitis, STI history of patient and sexual partner(s).
  • Sex practices within past year (sex of partners, type of sex, use of HIV prevention/pregnancy prevention).

Provide appropriate referrals and/or counseling based on the assessment. For example: if patients intend to have children, what are the next steps? Preconception visit, vitamins, fertility checks, adoption information, etc.

Disclosure Counseling and Follow-Up

Disclosure counseling and support should be part of regular patient care of all people living with HIV. At PRO Men, we learned that for many men (regardless of their orientation), disclosure is not as difficult when talking to a potential male sex partner. On the other hand, many felt disclosing to a woman carried huge risks. Many men felt they could have casual sex with a woman, but that long-term relationships (and having kids) was not feasible, because it would require disclosure.

Disclosure counseling:

Provide options around disclosure: Start by assessing where the patient is at by asking questions like:

  • How do you feel about disclosure?
  • What are the worst things that could happen if you disclosed?
  • What are the benefits of disclosure?
  • What do you think it would look like to disclose?
  • Have you ever imagined having a talk about disclosure? If so: how did you imagine doing it? How did you imagine it went?

If the patient hasn’t gone that far yet in their mind, or if talking about disclosure causes anxiety, ask permission to tell them about options.

If the patient expresses interest in disclosing, talk about planning a time and place when they can have a conversation. Some have chosen to ask their partner to come to clinic for a joint visit with their provider, social worker or counselor.

The most important thing is the patient feels as ready and prepared as possible to disclose to their partner(s) or others.

Planning and preparing for disclosure:

Role playing is a great and important tool in helping patients become comfortable with the conversation. There are many ways to do it, and there is no perfect way. Counsel your patient that if it doesn’t feel right, try again until it does.

Give constructive feedback: give praise about what worked well, and practical ideas about what might have worked better. Ask: How did it feel? What reactions or questions might their partner have?

Create a plan with your patient if disclosure does not go as planned. Ensure there is a safety plan in place. Provide your phone number or an after-hours number in case immediate support is required.

Post-disclosure debriefing:

Debriefing serves several goals: 1) It provides an opportunity for patients to process their experiences and think of what they may want to do going forward. 2) It can help solidify, repair, or maintain their relationship with their provider, their partner(s) and anyone else involved. 3) Finally, providers can learn from what patients tell them about their disclosure experience. These learnings can help providers give better counsel to the next patient.

Schedule an appointment to see the patient the same day or day after the disclosure. In case disclosure doesn’t happen as planned, encourage patients to debrief with you whenever they have disclosed.

Offer joint primary care visits if the patient wants assistance with disclosure. The patient can have their provider, social worker, or clinic champion assist with disclosure. The clinic champion can also coach the providers on supporting their patients during this process. At the end of the visit, create a primary care follow-up plan that includes the partner. This usually involves HIV testing for the partner and can include PEP/PrEP. Consider referring female partners for contraception and/or safer conception counseling.