What is included in pregnancy planning for patients with HIV infection?

Updated: Apr 02, 2019
  • Author: Ashley T Peterson, MD; Chief Editor: Ronald M Ramus, MD  more...
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Answer

Answer

Preliminary data suggest that women with HIV may suffer from subfertility. Conception in couples who have never conceived may occur in a median of 6 months with 2 acts of intercourse during the ovulatory period of the cycle. With each act, the risk of sexual transmission must be considered even in the presence of an undetectable viral load.

In couples planning a pregnancy where only the female is HIV-infected, assisted insemination at home or with a treatment provider with her partner’s semen is the safest conception option after ART (antiretroviral therapy) has been initiated and maximum viral suppression has been attained.

In couples planning a pregnancy where only the male partner is infected, natural conception carries a risk of sexual transmission to the uninfected female and alternatives to natural conception are the safest options. Safe alternative options include adoption or sperm donation with assisted reproduction techniques. If a couple cannot or declines alternatives to natural conception, counseling regarding pre-exposure prophylaxis(PreP), sperm analysis, sperm washing, and transmission risks should be reviewed. While antiretroviral therapy can reduce viral load in the blood to undetectable levels, semen analysis is recommended prior to attempting conception as HIV-infected men can still have a substantial viral concentration in semen in the presence of an undetectable plasma viral load. If HIV viral load cannot be suppressed, semen washing can be considered with appropriate counseling as it may decrease the HIV RNA and DNA to undetectable levels. After processing and rechecking for residual contamination, the spermatozoa can be used for intrauterine insemination or in vitro fertilization.

Pregnancy does not appear to influence the progression of HIV disease. [15] A large cohort of French women with known seroconversion dates noted a pregnancy-adjusted relative risk of progression from HIV to AIDS of 0.7. [16] Furthermore, pregnancy does not seem to affect survival of women infected with HIV. [17]

For concordant couples (both partners are HIV-infected) who wish to conceive, both partners should attain maximum viral suppression and be screened and treated for genital tract infections before attempting conception. For serodiscordant couples who want to conceive, in addition to above, counseling should include the recommendation to only attempt conception once antiretroviral therapy (ART) is started and viral loads are undetectable. Additionally, NIH guidelines include educating patients regarding PrEP in serodiscordant couples. Recommendations regarding periconception administration of antiretroviral PrEP for HIV-uninfected partners are an additional tool to reduce the risk of sexual transmission and are continually evolving. The current guidelines include information on counseling, laboratory testing, and monitoring of individuals on PrEP and the importance of reporting uninfected women who become pregnant on PrEP to the Antiretroviral Pregnancy Registry. FDA labeling information and perinatal ART guidelines permit off-label using in pregnancy, however safety data regarding teratogenicity are limited. [18, 19, 20]

HIV-infection risk-reduction strategies in conjunction with relatively inexpensive fertility awareness methods (FAMs) may be useful for counseling HIV-serodiscordant couples who want to conceive. [21] Such methods include use of accessible and highly sensitive, but poorly specific, strategies like the calendar method, basal body temperature measurements, and cervicovaginal mucus secretion features. Urinary luteinizing hormone testing has high specificity and cost with less sensitivity. Timed condomless sex has low cost but necessitates understanding how to precisely predict the fertile period in a menstrual cycle. [21]


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