Although many women do not learn their HIV status until they become pregnant, for those women who know they are HIV-positive prior to choosing to become pregnant, pre-conception assessments may inform both her and her partner of the safest way to become pregnant without HIV transmission to the infant or HIV transmission between serodiscordant couples. Therefore, throughout their reproductive years, women living with HIV need ongoing comprehensive pre-conception care that is incorporated into primary care services so they can make informed choices about pregnancy prior to conception.

Many Women Living with HIV Want Children, and Many Do Not

A study of 1,433 HIV-positive women on treatment in Cameroon in 2007 found that more than half wished to have a child or another child in the future (Marcellin et al., 2010a). Focus groups in South Africa found men and women to be very careful in weighing the choice to have a child and acutely mindful of the long-term consequences for themselves, their partners and their future child (London et al., 2008); however studies have found that women and men living with HIV do not always seek pre-conception counseling due to fear of stigmatization by health care providers. Many women living with HIV face heavy pressure from providers and others not to become pregnant (Orner et al., 2011a; Orner et al., 2010), including pressure for sterilization procedures. [See Meeting the Sexual and Reproductive Health Needs of Women Living With HIV] For people who living with HIV, marrying and having children offer the opportunity to lead normal lives. For women who are living with HIV, it may be possible to keep their positive serostatus confidential, but it is not possible to hide whether or not one is married or has children (Smith and Mbakwem, 2010). Stigma is a large obstacle that must be overcome in order to minimize the risk of perinatal transmission at the earliest possible point.

Fertility may be reduced among women who are living with HIV, but it is unclear whether this is related to non-biological factors such as reduced sexual exposure as a result of marital dissolution that sometimes occurs when a woman tests positive for HIV (Chen and Walker, 2010; Magadi and Agwanda, 2010). A review in 2010 of literature on this topic for South Africa concluded that HIV does result in reduced fertility (Basu et al., 2010). Another study in South Africa found that among 674 women, those women living with HIV were much less likely to want to have children, even with access to HAART: 31% of HAART users wanted children, 29% of those not on HAART wanted children but 68% of women without HIV wanted children (Kaida et al., 2011). While there is no direct biological reason concerning why HIV-positive women may be less fertile, people living with HIV are at increased risk of also acquiring other sexually transmitted infections (STIs) and STIs have been correlated with infertility (Hardee et al., 2012). [See also Treating Sexually Transmitted Infections (STIs)]

There is Conflicting Evidence Regarding the Risk of Acquisition During Pregnancy

Women should also know that studies conflict regarding an increased risk of HIV acquisition during pregnancy (Reid et al., 2010; Morrison et al., 2007; Gray et al., 2005), but that pregnancy does not increase the risk of early death (Allen et al., 2007a). A recent study has shown that even after adjusting for unprotected sex and contraceptive use, pregnancy was associated with a two-fold increased risk of HIV transmission from the female to male partner (Mugo et al., 2011). Ensuring that a pregnant woman has initiated antiretroviral therapy prior to becoming pregnant can reduce transmission to her HIV negative male partner. [See also Antenatal Care - Treatment] "Early initiation of ART is important to achieve undetectable viral load well before delivery; thus, women should be encouraged to plan pregnancies and attend antenatal care sufficiently early to diagnose HIV infection, assess the HIV stage, and initiate ART or antiretroviral prophylaxis as soon as possible" (Kesho Bora Study Group, 2011: 179). In addition, because TB is a risk factor for increased vertical transmission (Gupta et al., 2011), women living with HIV who wish to conceive should be considered for routine TB preventive therapy (Marais, 2011). In the future, pre-exposure prophylaxis may be used by women without HIV to reduce the risk of HIV transmission by HIV-positive male partners so that women could become pregnant while reducing their risk of acquiring HIV [See also Prevention for Women], though safety needs to be assessed (Mastro et al., 2011).

"It is also important to know your status even before you become pregnant so that you can at least know the ways of not letting the baby get infected." Kenyan woman (Center for Reproductive Rights and Federation of Women Lawyers, 2007)Providing serodiscordant couples with preconception counseling is an especially urgent need. Though a meta-analysis of studies from both high and low-resource settings found no relationship between pregnancy and HIV disease progression, "HIV sero-discordant couples face complicated choices between fulfilling reproductive desire and risking HIV transmission to their partners and children" (Matthews et al., 2010: 1975). One study found an increased risk of HIV seroconversion in discordant couples in which the woman became pregnant, suggesting that the intention to conceive may increase the risk of HIV acquisition (Brubaker et al., 2010). A review of pre-conception options for serodiscordant couples recommended that peak fertility may be achieved through pre-exposure prophylaxis and timed unprotected intercourse, along with screening and treatment of STIs, male circumcision and delayed conception until the HIV-positive partner is on treatment and virally suppressed with CD4 counts higher than currently recommended for HIV treatment in resource-poor countries (Matthews et al., 2010). Self-insemination can minimize the risk of transmission to partner and infant when a woman is HIV-positive and her partner is seronegative. When HIV transmission to the male partner is to be avoided, self-insemination of ejaculated sperm is advised. "... The data on the safety of unprotected intercourse in the HIV-infected serodiscordant couples attempting to conceive are rather limited..." (Semprini et al., 2008: 374). A report in Chile found that an HIV-positive woman used artificial insemination from her HIV-negative husband and gave birth to a healthy HIV-negative infant (Vivo Positivo and Center for Reproductive Rights, 2010). Fertility guidelines have been developed in South Africa by the HIV Clinicians Society to assist clinicians in low- and medium-resourced settings to discuss conception between HIV-discordant couples (Bekker et al., 2011 cited in Mastro et al., 2011).

Pre-Conception Care Can Protect Womens Health

Pre-conception care should include counseling on barrier methods of family planning to decrease transmission of HIV and prevent secondary infection, skills to negotiate condom use, assessment of a woman's nutritional status, education and counseling on perinatal HIV transmission and pregnancy risks, and support and counseling for partner disclosure on HIV status before pregnancy. "One of the difficulties in counseling serodiscordant couples on natural conception involving unprotected intercourse is that the risk to the uninfected partner is difficult to quantify but can certainly not be quoted as zero" (Fakoya et al., 2008). If both partners are HIV-positive, there is a potential that one partner can acquire superinfection, one that is possibly drug-resistant, from the other partner, and artificial insemination can be considered (Sherr, 2010). Specific recommendations include for health care providers to "ask about pregnancy intentions to every woman, every visit," and to discuss "the risks and effects of pregnancy on... [preexisting] medical condition[s], and the effects of the medical condition on pregnancy outcomes... so that the patient can make an informed decision about becoming pregnant... Education and counseling for HIV-infected women about perinatal HIV transmission risks, strategies to reduce those risks, the potential effects of HIV or its treatment on pregnancy, and the risk of transmission during breastfeeding, allows patients to be fully aware of the issues concerning HIV infection and pregnancy before conception" (Aaron and Criniti, 2007: 139).

"For those with access to fertility centers, longitudinal data show that conception can occur with a very low risk of HIV transmission... While the experience with assisted reproductive health technologies is encouraging, access to these treatments remains limited even for those individuals in resource-rich settings... Teaching couples about ovulation and intercourse timed to fertile periods offers a means for decreasing the number of unprotected sexual encounters" (Matthews and Mukherjee, 2009: S7).

While maternal health services traditionally do not provide pre-conception care but rather start once a woman is pregnant with antenatal care, women with HIV can benefit from pre-conception care. As PMTCT programs are scaled up, including pre-conception care as part of maternal health services should be considered. Increasingly, services will also be needed to provide counseling and support for perinatally infected adolescents who will want to know their options for pregnancy, birth and infant feeding to minimize the probability of transmission to the infant and yet protect their own health (Birungi et al., 2009a; Birungi et al., 2009b). Maternal health providers often lack the knowledge needed to guide women living with HIV through a safe pregnancy process and may discriminate against women living with HIV. Training is needed to ensure that providers will support womens choices in reproductive health. [See also Meeting the Sexual and Reproductive Health Needs of Women Living With HIV] Existing guidelines in countries such as South Africa, Canada and the United States (Bekker et al., 2011; USHHS, 2011; Loutfy et al., 2012) could possibly be adapted for wider use, depending upon country contexts.