preventing HIV transmission have changed radically in the last two years. In
2011 and 2012, research demonstrating the efficacy of HIV treatment as
prevention13 and the potential effectiveness of pre-exposure
prophylaxis (PrEP) was published. Both findings are beginning to have, and will
continue to have, a significant impact on the recommended routes for safer
conception for people living with HIV.
quotations from Plus One, from
couples desperate to conceive, it is easy to understand why there has been so much
excitement about new recommendations for less invasive, less expensive, but
still safer conception, and why it is important that they are implemented
“I have been told that I might have
sex with her without a condom if I want babies, some sort of the risk of her
being infected is very low. [...] people they talk like that but it is, I have
heard about that [...] But is it true anyway that statement?” Male, positive
about whether or not it is safe to conceive by unprotected intercourse (as
expressed in the quote above) is not surprising, given how recent the news on
the effectiveness of treatment as prevention is.
summarise, a pivotal study (referred to as HPTN 052) involving over 1700
couples, showed that there was a 96% reduction in transmission between
heterosexual discordant couples if the partner with HIV was taking
antiretroviral therapy (ART).14 This confirms that the risk of
sexual HIV transmission is very low when someone with HIV is taking effective
HIV treatment and meets certain criteria. This concept is often referred to as
‘treatment as prevention’ or TasP.
HPTN 052 confirmed what a lot of doctors had suspected for
some time: if a person with HIV is taking treatment, the likelihood of their
transmitting HIV is reduced to such an extent that in many cases a
serodiscordant couple and their doctor may regard this as sufficient protection
from HIV. In the light of these findings, a significant revision of fertility
guidelines was warranted.
NICE’s draft revised fertility guidelines are due to be
published in a final version in autumn 2012. They are likely to include a new
recommendation for heterosexual couples wanting to conceive. NICE says that, in
certain circumstances, using treatment to prevent transmission
during unprotected sex is as safe as sperm washing, to enable
conception between an HIV-positive man and an HIV-negative woman. Providing the
following conditions are met, serodiscordant unprotected sex is considered a
safe method of conception:
intercourse is limited to the time of ovulation.
- The man is on
highly active antiretroviral therapy (HAART) and is adhering to his treatment
- The man has a
plasma viral load of less than 50 copies/ml (an ‘undetectable’ viral load).
- Neither partner
has any other sexually transmitted infections.15
If any conditions are not met, or if
a couple believes the risk of unprotected intercourse is unacceptable, NICE
still recommends considering sperm washing. You will need to discuss whether or
not this might be a suitable option for you with your partner and your doctor.
It is thought that some clinicians, who have independently
reviewed the evidence, have been recommending this approach for some time.
NICE does not mention this situation specifically, but it
might be assumed that in couples where both partners are living with HIV, but
have infection with different strains, they might also follow this guidance for
safer conception, providing all the conditions are met.
At the moment, NICE is not planning to change its advice for
women with HIV whose partner is HIV negative.
In contrast, the Greater Manchester
Sexual Health Network also reviewed its advice in 2012 and came to the opposite
conclusion. Its advice for couples wishing to conceive by unprotected
“UPSI [unprotected sexual intercourse] is not recommended either in this
protocol or in national BHIVA guidelines; [the] only recommended option is
sperm washing due to risk of transmission.”
At the moment, different clinicians
and guidelines are saying different things about the safety and risk of
unprotected intercourse, in combination with treatment as prevention, for
conception. Once NICE publishes its guidelines, it is likely that local
guidelines, such as those from Manchester,
will be revised again. Until then, the contradictory advice available from
different sources is likely to be confusing. To make sure you get the best
advice, it’s best to start discussions with your doctor early. They, and other
staff at your HIV clinic, will be able to talk through your particular
situation and what options may be open to you. They can also talk to you about
preparations you can make for pregnancy, such making sure you are in the best