Safer conception services for HIV-affected couples must address overlooked relationship dynamics: a commentary and call to action

Data from East and Southern Africa shows the desire for children is strong among people living with HIV (PLHIV). Concurrently, many new HIV infections in East and Southern Africa occur in long-term sero-different relationships and may be due to the couples' attempts to become pregnant. Safer conception (SC) is a promising sexual and reproductive health service for PLHIV in Africa, yet it remains underutilised for high-priority at-risk populations, presenting a missed opportunity to prevent HIV transmission. Relationship-focused couples' interventions have improved sexual and reproductive health and HIV outcomes in East, West, and Southern Africa, but this approach has not been employed in the SC realm. We suggest a shift in SC interventions by moving from an individual-level approach (e.g. approaches focused on women or men separately), to a couples-based approach informed by a couples-based theoretical model. While promising, most existing SC interventions are limited by their emphasis on individuals instead of couples, thereby failing to recognise that each partner influences the behaviours of the other either directly or indirectly. Also, existing interventions offering SC services and counselling to couples have not tried to address relationship dynamics to improve biobehavioral outcomes. We are guided by Lewis et al.'s Interdependence Model of Health Behavior Change, which posits that both partners can influence each other's health behaviours and HIV prevention decisions. SC presents an avenue for reaching sero-different couples desiring children, making it an ideal window of opportunity to engage couples in HIV care and prevention and sexual and reproductive health services.