Preconception, planned pregnancy, and your rights to have a baby

Many HIV positive women become pregnant when they already know their HIV status. Many women are also already taking anti-HIV drugs when they become pregnant. If you already know that you are HIV positive, you may have discussed the possibility of becoming pregnant as part of your routine HIV care – whether this pregnancy was planned or not.

If you are planning to get pregnant, your healthcare provider will advise you to:

• Consider your general health.
• Have appropriate check ups.
• Treat any sexually transmitted infections (STIs).

You should also make sure you are receiving appropriate care and treatment for your HIV.

It is reassuring that over 98 percent of HIV positive pregnant women have uninfected babies in the UK currently.

Choose a healthcare team and maternity hospital that supports and respects your decision to have a baby.

If you are not supported in this decision, then arrange to see a doctor and healthcare team with more experience in dealing with HIV.

You may not be able to travel to a centre with this expertise. In this case, you should contact them for advice, support and to find out your rights.

In this section, as well as options for HIV positive women (with either negative or positive partners) wishing to get pregnant, we look at safer conception for HIV negative women with HIV positive partners.

There is still controversy over the best advice to give to serodifferent (the medical term is serodiscordant) couples. (These are terms for when one partner is HIV positive and the other HIV negative.)

If serodifferent couples have unsafe sex there is always a potential risk of transmitting HIV. Even when politely called a “conception attempt” under the safest conditions, there is always a theoretical risk, even when this is extremely low, that the HIV negative partner will contract HIV.

Until quite recently, conceiving through timed unprotected intercourse was rarely officially recommended.

Newer evidence though, supports this as a much more practical option and discussing this option with your healthcare providers is important.

With the help of their healthcare team, couples can weigh up, based on a growing body of research, the risks and benefits in their individual case, and whether the risk is acceptable to them.

HIV transmission during vaginal intercourse depends on several factors. For couples in stable, monogamous relationships that wish to conceive, the most important considerations are:

• The viral load of the HIV positive partner.
• Whether there are other STIs.
• Frequency of intercourse.

For example, if an HIV positive man is in a monogamous relationship and not taking HAART the risk of transmission to his HIV negative female partner is estimated in some studies to be 0.1 to 0.3 percent for each act of intercourse.

The risk of transmission from an untreated HIV positive woman to an HIV negative man is estimated to be 0.03 to 0.09 percent.

The risk is a lot lower in people with an undetectable viral load in blood plasma taking HAART.

Viral load in plasma has quite good correlation with viral load in genital secretions.

But, HIV has been detected both in semen in HIV positive men and the fluid in the uterus and surrounding the ovum in HIV positive women, even when their viral load was undetectable with HAART.

Having an STI (eg syphilis, chlamydia) increases the HIV viral load in genital secretions but not in plasma.

It is difficult for doctors (or for us) to give sero-different couples precise advice. It is known that the risk of timed, unprotected intercourse, where the HIV positive partner is on treatment with an undetectable viral load for more than six months, is very low. But it is not completely zero.

Mathematical models have suggested a risk of 1 in 100,000 per act of intercourse.

Mathematical models are used a lot by scientists to answer “what if?” questions. They simulate real life situations with mathematical equations. Known information will be entered into a computer programme and the system will generate answers.

Answers from mathematical models are not the same as answers from real life research, but they can be pretty useful in helping us understand what an outcome is likely to be.

A very large study recently reported some very important news.

In May of this year, the results from the HIV Prevention Trials Network (HPTN) Study 052 provided proof that HAART can make HIV positive people less infectious to their HIV negative partners.

HPTN 052 is the first randomised controlled trial (RCT) to demonstrate a reduction in infection.

The study was multinational and conducted with over 1700 serodifferent couples. It compared the effect of starting HAART immediately – defined as a CD4 count between 350 and 550 cells /mm3 – to delaying starting until the positive partner reached a CD4 count of less than 250 cells/mm3.

The results showed that starting HAART at higher CD4 counts lowered the risk of HIV transmission by a remarkable 96 percent. The study was stopped early as the benefits were shown more quickly than anticipated in the original design for the trial.

The only prospective study to look at transmission risk in serodifferent couples attempting to conceive naturally, where the HIV positive man had an undetectable viral load on HAART, and the woman received pre-exposure prophylaxis (PrEP) was with 22 couples. In this study, intercourse was timed to the woman’s fertile period and there was a 50 percent conception rate.

The same researchers had reported earlier from a retrospective review of 74 couples (52 with an HIV positive man and 22 with an HIV positive woman) in which the positive partner was on HAART, intercourse was timed, and there were no transmissions.

If you do decide that this is the most acceptable way of conception for you and your partner you need to make sure:

• The HIV positive partner is adherent.
• The HIV positive partner has regular viral load checks.
• Both partners have STI screening.
• Both partners have fertility screening.
• Both partners understand when the woman is most fertile.
• The HIV negative partner considers using PrEP.

Some clinics will ask you to sign a form confirming that you have received pre-conception counselling and that you fully understand the risks involved.

One additional point should be stressed. Although a low number of conception attempts can be relatively safe, some couples do not return to safer sex afterwards. This sometimes results in the negative partner then becoming HIV positive.

HIV is still a disease that can affect the rest of your life. If one of you has stayed HIV negative until now, you don’t want to change this over a decision to have a baby.