Throughout the decade, scientific research has brought into increasingly sharp focus the awesome power of antiretrovirals (ARVs) to prevent HIV transmission.
Mounting evidence suggests that people with HIV virtually eliminate their risk of transmitting the virus to others by fully suppressing their virus through ARV treatment. (This is known as HIV treatment as prevention, or TasP). In fact, the risk of transmitting HIV with an undetectable viral load may be zero.
Additionally, HIV-negative people who stick to the daily regimen of Truvada (tenofovir disoproxil fumarate/emtricitabine) as pre-exposure prophylaxis (PrEP) likely benefit from a similarly high level of protection against the virus. And we’ve known for decades that expectant mothers with HIV can keep from passing along the virus to their babies if they’re on ARVs.
All this is excellent news for those looking to conceive a child when one or both of the prospective parents are living with HIV. Having a baby without transmitting the virus to the parent or the baby can now be as simple as taking a pill every day—without significant medication toxicities.
Sperm washing, while quite expensive, is another means of protecting a pregnant woman from contracting HIV from a man living with the virus. For HIV-positive gay men, this remains a central option for having a biological child.
Below are three scenarios involving a potential parent living with HIV. To follow are more detailed scientific explanations of the safety and effectiveness of various options for conceiving a child without transmitting the virus.
The Woman Has HIV:
Shannon Weber, MSW, is the director of HIVE, a long-running program at San Francisco General Hospital that provides preconception or pregnancy care to women living with or affected by HIV. She points to a home-insemination how-to brochure on HIVE’s website. It guides an HIV-positive woman through the process of depositing an HIV-negative man’s ejaculate into a sterile cup or non-spermicide condom, drawing the semen into a needleless syringe, and inserting it into her vagina. (Standing on one’s head afterward isn’t one of the steps, but Weber says it couldn’t hurt!)
Women living with HIV can otherwise rely on TasP to keep from transmitting HIV to their male partner during sex without a condom. Also, the man could take PrEP, as an added layer of protection or as an alternative to TasP.
Straight Couple, the Man Has HIV:
Dominika Seidman, MD, a family-planning fellow at the University of California, San Francisco and a clinician at HIVE, counsels HIV-negative women looking to have a child with an HIV-positive about an array of options. If they want to have condomless sex, there’s TasP for the woman and PrEP for the man, with one or both of the couple taking daily ARVs to protect against HIV transmission. They can otherwise seek intrauterine insemination (IUI) or in vitro fertilization (IVF) with sperm washing (more on sperm washing in the next section), although this can be very expensive. Or if they prefer they could go for adoption or use sperm donation from an HIV-negative donor.
“Poppy Morgan,” who writes a blog called HIV Negative Spouses, was one of the first women in the country to conceive a child with the help of PrEP. (She writes under that pseudonym to protect her privacy because she’s a public figure.) The 41-year-old is married to an HIV-positive man who maintains an undetectable viral load thanks to ARV treatment. In 2012, he got her pregnant through good old-fashioned sex without a condom. The couple now has a 3-year-old daughter. Both the mother and child are HIV-free.
Unfortunately, as Morgan attests, women can have a particularly hard time finding a physician willing to prescribe them PrEP. She had one physician refuse to do so on the grounds that it would be “enabling risky behavior.”
Living in San Francisco at the time, Morgan was aware of how PrEP was considered an important new form of harm reduction for MSM, as public health experts strove to find ways to prevent HIV transmission among men having condomless intercourse, rather than pushing condoms as the only way to lower their HIV risk. Yet when it came to something as fundamental as getting pregnant, the medical gatekeepers she encountered questioned her desire to conceive, dismissing her doing so as merely elective.
Morgan says such attitudes were “discriminatory in a way, because I’m a woman.”
After she finally received a Truvada prescription from her husband’s HIV specialist, Morgan says she felt “there was a level of validity” to the conception of her child, “because it was under the care of a doctor and we weren’t just going rogue having condomless sex.”
An HIV-Positive Man and a Surrogate:
HIV-positive men seeking to conceive their own child with a surrogate could possibly rely on TasP or PrEP to safely impregnate the woman, for example, through non-intercourse-based home insemination as described above. Seidman recommends a joint health care visit before attempting conception to go over options and to handle legal paperwork, including the man’s disclosure of his HIV status and viral load.
Outside of such a conception route, HIV-positive men are looking at surrogacy through IUI or IVF along with sperm washing as their core options. All sperm is washed for those procedures, meaning it is separated from other particles in a centrifuge. Special facilities handle sperm from HIV-positive men; there are only a handful of these operations in the country.
IUI with sperm washing may cost around $1,000 to $2,000 per cycle, while IVF runs about $12,000 to $15,000 per cycle, according to Mark V. Sauer, a professor of obstetrics and gynecology at Columbia University who was one of the first U.S. clinicians to develop insemination methods using sperm from HIV-positive men.
Note that the laws governing surrogacy, sperm donation and sperm washing and eventual parental rights in such a context differ from state to state. In some states it is in fact illegal for an HIV-positive man to knowingly inseminate an HIV-negative woman. Sauer says he doesn’t know of any physicians who have been charged with a crime for assisting with such an insemination. But such state laws are “a huge deterrent to physician involvement,” he says.
For a brochure from HIVE on parental options for HIV-positive gay men, click here.
TasP and PrEP, Crunching the Numbers:
Just how effective are TasP and PrEP at preventing HIV transmission? News out of the 21st International AIDS Conference in Durban, South Africa (AIDS 2016), which took place in July, has helped refine scientists’ understanding of each method’s considerable power.
Two major studies of mixed-HIV-status couples presented at the conference, HPTN 052 and PARTNER, showed that when the partner living with the virus had an undetectable viral load, there were no transmissions within the couples. This held true for both heterosexual couples and couples consisting of two men. In the ongoing PARTNER study, the male-female couples have so far collectively engaged in intercourse without a condom an estimated 36,000 times and the male-male couples have done so some 22,000 times.
PARTNER’s lead researcher, Alison Rodger, MD, an infectious disease specialist at University College London, acknowledges, “No study can ever prove that this risk is absolutely zero.” But Rodger says she and her colleagues have collected enough data on mixed-HIV-status heterosexual couples to allow them to place considerable faith in treatment as prevention.
For these couples, she says, “The risk of HIV transmission via condomless vaginal sex is extremely low and likely negligible provided that the HIV-positive person has been on fully suppressive antiretroviral therapy for several months and maintains full compliance with his or her prescription.”
In another study presented at the AIDS 2016 conference, Partners PrEP, researchers gave PrEP as a “bridge” to over 1,000 mixed-HIV-status heterosexual couples until the HIV-positive partner started ARVs and was on them for six months. Mathematical modeling suggested that without the study protocol, 40 participants would have transmitted HIV to their partners during the follow-up period. The study saw just two transmissions. Both cases included HIV-positive men passing the virus to their female partner. Neither couple was apparently taking ARVs at the time, either as treatment for the virus or as PrEP.
Partners PrEP and a study of PrEP use among high-risk women called FEM-PrEP provide data on the safety of taking Truvada during conception. Neither study showed that PrEP was associated with birth defects or miscarriage. A major limitation of these studies, however, is that the participants stopped receiving PrEP once tests confirmed they were pregnant. So there isn’t good data on PrEP’s safety when taken throughout gestation.
According to Seidman, there is, on the other hand, robust data on the safety of ARVs, including Truvada, among HIV-positive pregnant women. She says the question of whether HIV treatment leads to birth defects “is practically put to rest,” thanks to all the information collected in a U.S. registry of anonymous data on HIV-positive pregnant women.
Researchers estimate that taking at least four tablets of Truvada per week provides maximum protection against HIV among MSM. There has thus far been only one documented case of a man contracting HIV from another man while apparently taking at least four tablets of Truvada per week—a Canadian who acquired a rare, highly drug-resistant strain of the virus.
Meanwhile, studies suggest that because of differences in how Truvada penetrates vaginal versus rectal tissues, women need to follow the daily regimen more closely to reap PrEP’s full benefits. (Seidman counsels her female patients that good adherence to the PrEP regimen lowers their risk of contracting HIV by more than 90 percent.) Plus, while MSM apparently need to take daily Truvada for about a week before achieving maximum protective drug levels, women likely need longer to reach such a point, perhaps as long as three weeks to be on the safe side.
Seidman and Weber, along with other researchers, recently published a study of 27 women who took PrEP before, during or soon after pregnancy, either at HIVE in San Francisco or a New York City clinic. Twenty-six of the women had an HIV-positive male partner and one had a male partner who had sex with men and whose HIV status was unknown. None of the women offered PrEP in the study contracted the virus. The study showed that women are often willing to take PrEP for pregnancy when it’s offered to them.
Relying on both TasP and PrEP to safely conceive a child may be statistical overkill. Both HIV prevention methods are highly effective, and research thus far hasn’t shown that PrEP further reduces risk when combined with TasP. However, Weber points out that couples don’t always know all the factors that may influence their overall risk of transmission.
“People do go on and off their meds,” Weber says. “It’s really about the couple’s story and what works best for them. Maybe the [HIV-positive] guy wants the woman involved in his medical care, maybe he doesn’t. Maybe that’s private for him.”
Pregnancy and Nursing for HIV-Positive Women:
According to the Centers for Disease Control and Prevention (CDC), women with HIV
who are treated for the virus during pregnancy, refrain from breast feeding and have access to good HIV and prenatal health care have a less than 1 percent chance of passing along the virus to their baby.
“The general assumption is that if you are virally suppressed, you are highly unlikely to transmit HIV to the fetus,” says Devasena Gnanashanmugam, MD, who researches HIV-positive pregnant women at the National Institute of Allergy and Infectious Diseases (NIAID) in Rockville, Maryland.
Current U.S. HIV/AIDS medical practice guidelines do not recommend that women with HIV breast-feed because of the risk of transmitting the virus through breast milk and because formula is a safe alternative to nursing.
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