***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Integration of sexual and reproductive health within HIV care services is a promising strategy for increasing access to family planning and STI services and reducing unwanted pregnancies , perinatal HIV transmission and maternal and infant mortality among people living with HIV and their partners . We conducted a Phase II r and omized futility trial of a multi-level intervention to increase adherence to safer sex guidelines  among those wishing to avoid pregnancy and  adherence to safer conception guidelines  among those seeking conception in newly-diagnosed HIV-positive persons in four public-sector HIV clinics in Cape Town . Clinics were pair-matched and the two clinics within each pair were r and omized to either a three-session provider-delivered enhanced intervention ( EI ) ( onsite contraceptive services and brief milieu intervention for staff ) or st and ard-of-care ( SOC ) provider-delivered intervention . The futility analysis showed that we can not rule out the possibility that the  EI intervention has a 10 % point or greater success rate in improving adherence to safer sex/safer conception guidelines than does SOC ( p = 0.573 ) , indicating that the intervention holds merit , and a larger-scale confirmatory study showing whether the EI is superior to SOC has merit We examined the prevalence and correlates of safer conception methods ( SCM ) use in HIV-affected couples with fertility intentions . A prospect i ve cohort of 400 HIV clients in Ug and a who had fertility intentions with their partner was surveyed every 6 months for 24 months . Logistic regression analysis was used to determine individual , relationship and provider level predictors of SCM use . Over one-third ( 35 % ) reported any use of timed unprotected intercourse ( TUI ) during the study ; use of other SCM was rare . Baseline predictors of any TUI use included lower social support , greater perceived provider stigma of childbearing , greater SCM awareness , greater control over sexual decision making in the relationship , inconsistent condom use , and the belief that a desire for childbearing impedes condom use . These findings highlight the need for policy and provider training regarding integration of safer conception counselling into family planning and reproductive health services for people living with HIV This study aim ed to determine changes in fertility intentions of HIV-1 infected and uninfected reproductive age women in Blantyre , Malawi . Participants were asked about their fertility intentions at baseline and at 3-month visits for 1 year . Time-to-event statistical models were used to determine factors associated with changes in fertility intentions . Overall , 842 HIV uninfected and 844 HIV infected women were enrolled . The hazard of changing from wanting no more children at baseline to wanting more children at follow-up was 61 % lower among HIV infected women compared to HIV uninfected women ( P < 0.01 ) after adjusting for other factors , while HIV infected women were ~3 times more likely to change to wanting no more children . The overall pregnancy rate after 12 months was 14.9 per 100 person-years and did not differ among 102 HIV uninfected and 100 infected women who became pregnant . HIV infection is a significant predictor of fertility intentions over time Objective Many people living with HIV in sub-Saharan Africa desire biological children . Implementation of HIV prevention strategies that support the reproductive goals of people living with HIV while minimizing HIV transmission risk to sexual partners and future children requires a comprehensive underst and ing of pregnancy in this population . We analyzed prospect i ve cohort data to determine pregnancy incidence and predictors among HIV-positive women initiating antiretroviral therapy ( ART ) in a setting with high HIV prevalence and fertility . Methods Participants were enrolled in the Ug and a AIDS Rural Treatment Outcomes ( UARTO ) cohort of HIV-positive individuals initiating ART in Mbarara . Bloodwork ( including CD4 cells/mm3 , HIV viral load ) and question naires ( including socio-demographics , health status , sexual behavior , partner dynamics , HIV history , and self-reported pregnancy ) were completed at baseline and quarterly . Our analysis includes 351 HIV-positive women ( 18–49 years ) who enrolled between 2005–2011 . We measured pregnancy incidence by proximal and distal time relative to ART initiation and used multivariable Cox proportional hazards regression analysis ( with repeated events ) to identify baseline and time-dependent predictors of pregnancy post-ART initiation . Results At baseline ( pre-ART initiation ) , median age was 33 years [ IQR : 27–37 ] and median prior livebirths was four [ IQR : 2–6 ] . 38 % were married with 61 % reporting HIV-positive spouses . 73 % of women had disclosed HIV status to a primary sexual partner . Median baseline CD4 was 137 cells/mm3 [ IQR : 81–207 ] . At enrolment , 9.1 % ( 31/342 ) reported current pregnancy . After ART initiation , 84 women experienced 105 pregnancies over 3.8 median years of follow-up , yielding a pregnancy incidence of 9.40 per 100 WYs . Three years post-ART initiation , cumulative probability of at least one pregnancy was 28 % and independently associated with younger age ( Adjusted Hazard Ratio ( AHR ) : 0.89/year increase ; 95%CI : 0.86–0.92 ) and HIV serostatus disclosure to primary sexual partner ( AHR : 2.45 ; 95%CI : 1.29–4.63 ) . Conclusions Nearly one-third of women became pregnant within three years of initiating ART , highlighting the need for integrated services to prevent unintended pregnancies and reduce periconception-related risks for HIV-infected women choosing to conceive . Association with younger age and disclosure suggests a role for early and couples-based safer conception counselling Introduction : Pre-exposure prophylaxis ( PrEP ) may be an important safer conception strategy for HIV-1–uninfected women with HIV-1–infected partners . Underst and ing medication adherence in this population may inform whether PrEP is a feasible safer conception strategy . Methods : We evaluated predictors of pregnancy and adherence to study medication among HIV-1–uninfected women enrolled in a r and omized placebo-controlled trial of PrEP among African HIV-1–serodiscordant couples . Participants were counseled on HIV-1 risk reduction , contraception , and adherence and tested for pregnancy at monthly study visits . Pill counts of dispensed drug were performed and , at a subset of visits , plasma was collected to measure active drug concentration . Results : Among 1785 women , pregnancy incidence was 10.2 per 100 person-years . Younger age , not using contraception , having an additional sexual partner , and reporting unprotected sex were associated with increased likelihood of pregnancy . Monthly clinic pill counts estimated that women experiencing pregnancy took 97 % of prescribed doses overall , with at least 80 % pill adherence for 98 % of study months , and no difference in adherence in the periconception period compared with previous periods ( P = 0.98 ) . Tenofovir was detected in plasma at 71 % of visits where pregnancy was discovered . By multiple measures , adherence was similar for women experiencing and not experiencing pregnancy ( P ≥ 0.1 ) . Conclusions : In this clinical trial of PrEP  , pregnancy incidence was 10 % per year despite excellent access to effective contraception . Women experiencing pregnancy had high medication adherence , suggesting that PrEP may be an acceptable and feasible safer conception strategy for HIV-1–uninfected women with HIV-1–serodiscordant partners Background Increased fertility rates in HIV-infected women receiving antiretroviral therapy ( ART )  have been attributed to improved immunological function ; it is unknown to what extent the rise in pregnancy rates is due to unintended pregnancies . Methods Non-pregnant women ages 18–35 from four public-sector ART clinics in Johannesburg , South Africa , were enrolled into a prospect i ve cohort and followed from August 2009–March 2011 . Fertility intentions , contraception and pregnancy status were measured longitudinally at participants ' routine ART clinic visits . Findings Of the 850 women enrolled , 822 ( 97 % ) had at least one follow-up visit and contributed 745.2 person-years ( PY ) at-risk for incident pregnancy . Overall , 170 pregnancies were detected in 161 women ( incidence rate [ IR ] : 21.6/100 PY [ 95 % confidence interval ( CI ) : 18.5–25.2 ] ) . Of the 170 pregnancies , 105 ( 62 % ) were unplanned . Unmet need for contraception was 50 % higher in women initiating ART in the past year as compared to women on ART>1 year ( prevalence ratio 1.5 [ 95 % CI : 1.1–2.0 ] ) ; by two years post-ART initiation , nearly one quarter of women had at least one unplanned pregnancy . Cumulative incidence of pregnancy was equally high among recent ART initiators and ART experienced participants : 23.9 % [ 95 % CI : 16.4–34.1 ] , 15.9 % [ 12.0–20.8 ] , and 21.0 % [ 16.8–26.1 ] for women on ART 0–1 yr , > 1 yr–2 yrs , and > 2 yrs respectively ( log-rank , p = 0.54 ) . Eight hormonal contraceptive failures were detected [ IR : 4.4 [ 95 % CI : 2.2–8.9 ] , 7/8 among women using injectable methods . Overall 47 % ( 80/170 ) of pregnancies were not carried to term . Conclusions Rates of unintended pregnancies among women on ART are high , including women recently initiating ART with lower CD4 counts and higher viral loads . A substantial burden of pregnancy loss was observed . Integration of contraceptive services and counselling into ART care is necessary to reduce maternal and child health risks related to mistimed and unwanted pregnancies . Further research into injectable contraceptive failures on ART is warranted Background : Physiologic and behavioral changes during pregnancy may alter HIV-1 susceptibility and infectiousness . Prospect i ve studies exploring pregnancy and HIV-1 acquisition risk in women have found inconsistent results . No study has explored the effect of pregnancy on HIV-1 transmission risk from HIV-1-infected women to male partners . Methods : In a prospect i ve study of African HIV-1-serodiscordant couples , we evaluated the relationship between pregnancy and the risk of HIV-1 acquisition  among women and HIV-1 transmission from women to men . Results : Three thous and three hundred and twenty-one HIV-1-serodiscordant couples were enrolled , 1085 ( 32.7 % ) with HIV-1 susceptible female partners and 2236 ( 67.3 % ) with susceptible male partners .  HIV-1 incidence in women was 7.35 versus 3.01 per 100 person-years during pregnant and nonpregnant periods [ hazard ratio 2.34 , 95 % confidence interval ( CI ) 1.33–4.09 ] . This effect was attenuated and not statistically significant after adjusting for sexual behavior and other confounding factors ( adjusted hazard ratio 1.71 , 95 % CI 0.93–3.12 ) . HIV-1 incidence in male partners of infected women was 3.46 versus 1.58 per 100 person-years when their partners were pregnant versus not pregnant ( hazard ratio 2.31 , 95 % CI 1.22–4.39 ) . This effect was not attenuated in adjusted analysis ( adjusted hazard ratio 2.47 , 95 % CI 1.26–4.85 ) . Conclusion : HIV-1 risk increased two-fold during pregnancy . Elevated risk of HIV-1 acquisition in pregnant women appeared in part to be explained by behavioral and other factors . This is the first study to show that pregnancy increased the risk of female-to-male HIV-1 transmission , which may reflect biological changes of pregnancy that could increase HIV-1 infectiousness Background : There is a paucity of data on the effect of antiretroviral medications on  male fertility . Couples affected by HIV-1 often have fertility intentions , and antiretroviral medications , as both treatment of HIV-1-infected persons and pre-exposure prophylaxis ( PrEP ) for uninfected persons , are part of peri-conception risk reduction . Methods : Within a r and omized , placebo-controlled trial of daily oral tenofovir disoproxil fumarate ( TDF ) and combination emtricitabine (FTC)/TDF PrEP for HIV-1 prevention conducted among heterosexual HIV-1-serodiscordant couples , we assessed the impact of TDF and FTC/TDF use on male fertility , measured as incident pregnancy in female partners of men assigned to PrEP vs. placebo . Results : Of the 2962 HIV-1-uninfected men partners , 986 were r and omized to TDF , 1013 to FTC/TDF , and  
    Output:
    
SCS acceptability was impacted by low client and provider knowledge about safer conception services , stigma around HIV-affected couples wanting children , and difficulty with HIV disclosure in HIV-affected couples .
Couples expressed desire to learn more about SCS ; however , provider training , patient education , SCS promotions , and integration of reproductive health and HIV services remain limited .
Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge .
SCS are not yet widely available to HIV-affected African couples .