Surmounting 'Confusing' HIV Conception Guidance

Heather Boerner

August 02, 2017

PARIS — The first step toward a successful pregnancy for an HIV-discordant couple is ensuring that the person infected with HIV is adherent to treatment and has a consistently undetectable viral load.

From there, physicians should offer choices, such as PrEP for the uninfected partner, condomless sex timed with ovulation, self-insemination, sperm washing, or reproductive services like in vitro fertilization, said Lynn Matthews, MD, from Harvard University in Boston.

"Our job is to teach people about the different options and help them make the selection that works best for them," she told Medscape Medical News.

That hasn't always happened. Recently, the Centers for Disease Control and Prevention (CDC) issued updated recommendations on sperm washing for HIV-positive men, as reported by Medscape Medical News. But the guidance seemed to suggest that when couples attempted condomless sex for conception, the HIV-positive partner should be taking suppressive therapy and the HIV-negative partner should be taking pre-exposure prophylaxis (PrEP). In fact, science shows that both work individually.

The CDC is planning to issue a correction, Richard Wolitski, PhD, director of the Office of HIV/AIDS and Infectious Disease at the CDC, said on a conference call with activists earlier this month.

An attempt to clarify the issue was made during a satellite session here at the International AIDS Society (IAS) 2017 Conference. Physicians discussed evidence-based practices to try to get closer to consensus about what safer conception in the era of treatment as prevention and PrEP really looks like.

Integrated HIV and Reproductive Care

A consensus statement published recently recommends the integration of reproductive healthcare and HIV services, so that providers can identify patients who want to become pregnant and help them conceive safely (AIDS Behav. Published online May 13, 2017).

The statement, which began its life at the IAS 2015 meeting, also suggests that providers offer safer conception services to people living with HIV — men and women — at each appointment, along with regular counseling on condom use and treatment adherence.

The first question physicians who care for people infected with or exposed to HIV should ask is, "what are your plans for having a family?" said Dr Matthews.

It is the provider's job to talk to patients about the risks they are willing to take, she explained. Some women are confident their partner has a suppressed viral load and opt to forgo PrEP. Other women are anxious without PrEP, even if the viral load of their partner has been undetectable for years. And still others might not feel comfortable talking to a partner about his viral load or might be unsure that he is monogamous.

For each of the partners, there is an option that will work, she said.

'Falsely Precise Numbers'

To help patients understand the risks, physicians need to be "immaculate" with their data, said Robert Grant, MD, from the University of California, San Francisco, who is lead investigator of the landmark iPrEx Pre-exposure Prophylaxis Initiative.

That does not mean including "falsely precise numbers" from the HIV Prevention Trials Network (HPTN) 052 treatment-as-prevention trial, which indicate that treatment is 96% effective, or even from iPrEx, which indicate that PrEP is 63% to 75% effective.

"If you start talking about numbers, it gets really confusing, really fast," Dr Grant said. "Patients are going to ask, 'What happened to the 30% of people using PrEP who got HIV anyway? Or what happened to the 4% of people on ART who transmitted anyway?'"

"The answer is that those people don't exist," he explained. They are the outcome of study designs that included placebos and datasets that included people who didn't actually take medication. The only reason that HPTN 052 didn't come out 100% effective is that one person transmitted HIV before he was virally suppressed. And in the PrEP trials, 30% to 40% of people had no evidence of HIV prevention drugs in their systems.

"They're not PrEP users and they're not like your patients," he said. "Can we adopt the U=U concept? It's clear and evidence-based."

U=U is the abbreviation for the undetectable-equals-untransmittable public information campaign, a movement started by people living with HIV that urges physicians, in particular, to start talking to their patients frankly about what an undetectable viral load means.

The Condom Debate

During the satellite session, the debate focused on ways to grapple with the fact of treatment as prevention, and its implication for condomless sex to achieve pregnancy, while offering patients all their options.

"I'm getting push-back from patients because there is this movement of U=U," said Susan Cu-Uvin, MD, from Brown University in Providence, Rhode Island.

"My partner is undetectable; why should I go on PrEP?" they ask. The answer is that "you don't control your partner taking ARVs — he may stop at any point — and STIs can happen," Dr Cu-Uvin explained.

After discussion of ways to counsel patients about condomless sex during ovulation, when ovulation test kits can be inaccurate, and the irregularity of some women's menstrual cycles, Reuben Granich, MD, from the International Association of Providers in AIDS Care, piped up. "I'm confused," he said.

"If you're suppressed, you're not going to transmit, so you can have as much sex as you want," he pointed out. "Why are you talking about some window" for condomless sex during ovulation?

Jacque Wambui, a woman from Kenya living with HIV who is part of the National Network of People with HIV and AIDS, gave Dr Granich a high five.

"This is what I'm saying," she told the crowd. "The provider will not initiate the conversation. Women must demand these services. If U=U, then U=U and that's that."

One provider countered, however, that "we need to be careful not to assume that once you're U, you're always U."

Options, Not Permission

In the end, said Nelly Mugo, MD, from the Kenya Medical Research Institute in Nairobi, patients will do what they want. "My take on it is, you're not in the bedroom."

"You can only give them the correct information, and the decision will ultimately be theirs," she said. "Reproductive services are a human right. But access to knowledge is a human rights issue also."

Dr Matthews, Dr Grant, Dr Cu-Uvin, and Dr Mugo have disclosed no relevant financial relationships.

International AIDS Society (IAS) 2017 Conference: Abstract WESA0206. Presented July 26, 2017.

Follow Medscape on Twitter @Medscape and Heather Boerner @HeatherBoerner

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