- Discussing the risk of vertical transmission with providers and/or other HIV-positive women with seronegative children can increase women’s confidence about preventing vertical transmission of HIV.
- When a couple is serodiscordant or both male and female partners are HIV-positive and wish to conceive, having an undetectable viral load and limiting unprotected sex to peak fertility (with the possible use of pre-exposure prophylaxis) may result in the lowest risk of perinatal transmission.
- Sperm washing may be used for an HIV-negative woman wishing to become pregnant with an HIV-positive male partner without acquiring HIV herself.
1. Discussing the risk of vertical transmission with providers and/or other HIV-positive women with seronegative children can increase women’s confidence about preventing vertical transmission of HIV.
A 1999-2001 study carried out with 329 HIV-positive women in Thailand found that some pregnant HIV-positive women (number not specified) who were originally advised to abort by providers (number not specified) but were then counseled on PMTCT subsequently chose to access PMTCT and have a child. One woman said: “A doctor told me about AZT and its effectiveness, that for every 10 children, only 3 to 5 children would contract HIV [an erroneous statement]. I wanted to try. I really needed my child so the information I learned from the doctor made me happier and I decided to keep my pregnancy and wait for the day that I would meet my child” (Yoddumnern-Attig et al., 2004: 39). The women were interviewed using a structured questionnaire. In-depth interviews were conducted among 60 HIV-positive women. Four participatory workshops were held on data analysis and report writing. Women interviewed were selected non-randomly from support groups, clinics, ANC clinics, NGOs and communities using dimensional sampling method. The dimensions used were age (15-25, 26-35, 36-49) and number of years from diagnosis. Women who met the criteria for both dimensions were selected based on convenient or snowball sampling techniques. Six focus group discussions were held with six to eight men.
Evaluation of the mothers2mothers (m2m) program in South Africa found that the m2m program provided a strong continuum of care to the women and infants. Compared to non-participants, m2m participants had greater psychosocial well-being and greater use of PMTCT services and outcomes. Postpartum program participants were significantly more likely to have disclosed their status to someone than non-participants, and to have done so prior to delivery. m2m seeks to reduce PMTCT, empower pregnant and postpartum women to improve their health and the health of their babies, fight stigma and encourage and support disclosure. The program offered education and psychosocial support to HIV-positive pregnant women and new mothers, assisted women to access PMTCT services, and followed up to ensure care of mothers and infants after delivery.
A study in Cuba found 28 of 55 women interviewed who had given birth in Cuba, said that their worries about transmitting HIV to their child subsided after discussing their pregnancy with doctors, learning about treatment and meeting HIV-positive women who had had HIV-negative children.
2. When a couple is serodiscordant or both male and female partners are HIV-positive and wish to conceive, having an undetectable viral load and limiting unprotected sex to peak fertility (with the possible use of pre-exposure prophylaxis) may result in the lowest risk of perinatal transmission. [See also Staying Healthy and Reducing Transmission]
A 2004-2007 study in Switzerland with 53 HIV-serodiscordant couples, with the male HIV-positive, used pre-exposure prophylaxis, HAART and timed unprotected intercourse resulted in a pregnancy rate of 66% after five attempts and 244 documented unprotected events of vaginal intercourse and no instances of HIV transmission to the HIV-negative woman. The HIV-positive male partner was on fully suppressive HAART. Pre-exposure prophylaxis “was used as a theoretical risk reduction strategy in a situation where the a priori risk is considered to be extremely low" (Vernazza et al., 2011: 2007).
A 2004-2008 prospective cohort study reported on 143 HIV-positive women in South Africa and found that women who conceived while on HAART had a risk of vertical transmission to their infant of 0.7% compared to 5.7% for women who initiated HAART while pregnant. No vertical transmissions to infants occurred from women who received HAART for more than 32 weeks prior to delivery. Women were observed at combined antenatal and antiretroviral clinics at two hospitals in Johannesburg. Mothers and infants were followed until infant HIV testing at 4-6 weeks postpartum.
A study of 68 HIV-positive women in Saudi Arabia, with the majority of pregnancies planned “and coordinated with care providers to ensure tolerance, adherence, and response to antiretroviral therapy before conception” (Edathodu et al., 2010: 16) resulted in no infants becoming vertically infected.
A 2008 review of the global literature on gynecologic issues for HIV-positive women found that there is a 4.3% probability of transmission within HIV-positive couples trying to conceive using timed intercourse (timing sex without condoms when the woman is most fertile in order to increase the likelihood of pregnancy). Viral load should be undetectable, STIs should be treated and ovulation predictors should be used to accurately time sexual contact. However, “there are very little data on which to based recommendations to the HIV-positive seroconcordant couple" (Cejtin, 2008: 726).
A randomized three-arm trial of oral pre-exposure prophylaxis among 4,758 HIV serodiscordant heterosexual couples from Kenya and Uganda was conducted, during which 288 pregnancies occurred. The Data and Safety Monitoring Board recommended discontinuation of the placebo arm of the trial because of the demonstration of the efficacy of pre-exposure prophylaxis. “Given the high efficacy for HIV protection in the Partners PrEP study, PrEP may offer a method for HIV-uninfected women with HIV-infected partners to reduce HIV risk during conception, which warrants further evaluation."
3. Sperm washing may be used for an HIV-negative woman wishing to become pregnant with an HIV-positive male partner without acquiring HIV herself.
Sperm washing isolates HIV-1 free spermatozoa tested for the presence of HIV and different assisted reproductive techniques can be used, such as intrauterine insemination. No cases of seroconversion were shown in 4,000 cycles of sperm washing (Bujan et al., 2007; Barreiro et al., 2006 cited in Coll et al., 2008).
A study in Italy from 2001 to 2003 with 43 couples with seropositive male and seronegative females where sperm samples were washed and used for fertilization resulted in a pregnancy rate of over 51%, with no seroconversion detected.
A Cochrane review concluded that evidence has shown that sperm washing has not led to seroconversion in women or their offspring, but noted that the strength of evidence is limited to observational data.