Today, for people living with HIV, treatment of the virus that causes AIDS with antiretroviral therapy allows individuals to live longer, healthier and fuller lives. Among mixed status, or serodifferent, couples — where one partner has HIV and the other does not — suppression of the virus also prevents transmission.
In fact, a recent CDC report published this month notes that three multinational studies following about 3,000 sexually active mixed status couples over many years — where the partner living with HIV was virologically suppressed by ART, and condoms weren’t used — found no cases of transmission of the virus to the partner who didn’t have HIV.
[See: The Fertility Preservation Diet: How to Eat if You Want to Get Pregnant.]
“This latest report is sure to highlight that treatment as prevention works. This intervention alone is enough,” says Shannon Weber, director of HIVE, a clinic based in Zuckerberg San Francisco General Hospital and Trauma Center that provides preconception and prenatal care to women and couples affected by HIV. Weber is the founder of PleasePrEPMe.org, a website that has a national directory of health providers who offer pre-exposure prophylaxis, or PrEP, an HIV prevention method.
The Morbidity and Mortality Weekly Report notes that “the risk for male-to-female sexual transmission of HIV in the absence of any prevention measures is estimated to be approximately 8 per 10,000 episodes of condomless intercourse.” That differs from when the virus is suppressed by ART such that the so-called viral load — in this case, a measurement of the amount of the HIV virus in the person’s blood — is undetectable for at least six months.
“There’s now studies that have thousands of couples in them that show when the person living with HIV has an undetectable viral load for six months that there have been zero linked HIV transmissions,” Weber says.
The CDC report, and the research it spotlights, reinforces a message emphasized by many leading HIV researchers and advocates like Bruce Richman, who’s the founding executive director of the nonprofit Prevention Access Campaign, an initiative that seeks to empower people living with HIV or vulnerable to HIV with accurate and meaningful information about their social, sexual and reproductive health. Prevention Access’ Undetectable = Untransmittable international movement broadcasts that the latest scientific evidence shows a person living with HIV who’s on effective treatment and has an undetectable viral load can’t transmit HIV to a partner. “People living with HIV on effective treatment do not transmit HIV — that’s a fact that’s well-proven,” Richman says. “But it’s not well-known. It’s a very controversial subject once you get out of the scientific community into the public.”
Likewise, the CDC report has major implications for mixed status couples wanting to conceive a child. That’s something that many mixed status couples have previously thought or been told — sometimes by misinformed health providers — was off the table or couldn’t be done safely. “The good news is that several highly effective HIV prevention options are available,” John T. Brooks, a senior medical adviser in CDC’s Division of HIV/AIDS Prevention, said in a statement provided by the CDC. “Antiretroviral therapy, pre-exposure prophylaxis and semen processing are all highly protective against transmission of HIV,” says Brooks, the lead author of the August MMWR report on the effects of ART to prevent transmission of HIV to women in couples attempting to conceive where the man is living with HIV.
“I think the message then to serodifferent couples is that you can have the sex life you want and you can have the family you want, and there’s lots of ways that we can support you,” Webber says. She encourages partners in mixed status couples to talk about their desires to have families and discuss those desires with their health providers, “so that they can do that in a way that minimizes HIV transmission risk.”
Where the man has HIV that’s effectively suppressed with ART, experts say the simplest option to conceive is by having condomless sex around the time a woman is ovulating. And it’s safe to do so without taking additional precautions, Webber reiterates.
“Pre-exposure prophylaxis (PrEP), a highly effective HIV prevention method in which the partner without HIV takes antiretrovirals in advance of potential HIV exposure, can also reduce the risk for a woman who is attempting conception with an HIV-infected man, especially if his viral load is not known or is detectable,” the CDC report notes.
The report continues that, “Semen processing with subsequent intrauterine insemination or in vitro fertilization also significantly and substantially reduces transmission of HIV from men to women.” HIV is known to reside in semen in men with HIV; and this process, which is also called “sperm washing,” separates seminal fluid from sperm. The sperm is collected and washed in a lab to remove cells that are infected with HIV, and testing is done to confirm that there’s no HIV present. The sperm is then used for assisted conception, such as intrauterine insemination or in vitro fertilization.
Experts note that condomless sex is also an option for mixed status couples to conceive, where a woman is living with HIV and the man is not, if the virus is suppressed. “Treatment as prevention works,” Weber reminds. “So if a woman has an undetectable viral load and they have sex and she’s ovulating, she can get pregnant.”
[See: 10 Weird Mind and Body Changes That Are Totally Normal During Pregnancy.]
For couples, where a woman has HIV and the man doesn’t, “who are really concerned about taking that condom off, they can do home insemination,” Weber says. “That’s where the man ejaculates into a non-spermicide condom and then using a needleless syringe, the woman injects his semen into her vagina,” she explains. “There’s absolutely no contact … so there’s zero risk of HIV transmission.”
Unlike in the early years of the HIV epidemic, transmission to a child from a mother with HIV is now uncommon in the U.S. where the mother has been diagnosed with HIV and is being treated for it; though that’s still a concern in many developing areas around the world where people with HIV don’t receive optimal care. ” Once the woman is treated, the risk of the fetus becoming infected becomes very, very low,” says Dr. Myron Cohen, a professor of medicine, microbiology and immunology, and epidemiology and director the of Institute for Global Health and Infectious Diseases at UNC School of Medicine in Chapel Hill, North Carolina.
Today, women are routinely screened for HIV during pregnancy. However, it’s best to know before conception if a woman thinks she may have the virus, experts say, since HIV can become more difficult to manage medically when it goes undetected and unabated — and to reduce transmission risk for the child. “It’s critically important that a woman knows her status,” Cohen says, adding that irrespective of whether a woman is pregnant, it’s important she receive treatment very early if she has HIV.
Experts say that type of universal treatment approach and the emphasis on men and women knowing if they have HIV has changed the landscape for all people with HIV — including those wishing to start families.
But barriers still remain: For mixed status couples considering using assisted reproductive technology to conceive — including those who have fertility issues — very few fertility clinics currently treat couples where the man has HIV because of a decades-old recommendation from the CDC against insemination with semen from men with HIV. That guidance, which is now obsolete, came before dramatic treatment improvements.
The American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine emphasize that HIV should be considered a chronic disease or disability, that it shouldn’t result in discrimination and that fertility treatment should be offered if it’s desired.
The August MMWR update was welcomed by many HIV experts and advocates following a June MMWR that was met by a more mixed reception. “The previous CDC statement published in the June MMWR implied that assisted reproductive technology (such as in vitro fertilization) provided the safest and best approach to conception for couples with men living with HIV and women without HIV,” says Dr. Judy Levison, a professor of obstetrics and gynecology at Baylor College of Medicine, and physician coordinator of a program that provides obstetric and gynecological care for women living with HIV in the Harris Health System in Houston. “Although it was a huge leap forward for the CDC to remove its 1988 recommendation against insemination with the semen of men living with HIV, many of us who work in the clinical world of HIV felt the article mistakenly suggested that IVF is the ideal way to attempt conception and prevent HIV acquisition by the partner not living with HIV.”
The August MMWR did not place the same emphasis on assisted reproductive technologies in listing options for mixed status couples to safely conceive, while highlighting the effectiveness of all options, including antiretroviral treatment as prevention.
[See: Why Can’t I Get Pregnant?]
The bottom line, experts say, is that mixed status couples who wish to have a child should be encouraged to have that conversation and include their health providers to determine the best way forward to start a family.
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How to Safely Conceive When a Partner Is Living With HIV originally appeared on usnews.com
