University of California, San Francisco Logo

University of California, San Francisco | About UCSF | Search UCSF | UCSF Medical Center

transparent gif
transparent gif
Home > Topics > Emerging Issues > HIV and Reproduction
transparent gif

Counseling HIV-Infected Patients Who Want to Have Children

Transparent Image
transparent gif
Introduction
transparent gif
Counseling Concordant Couples
transparent gif
Counseling Discordant Couples
transparent gif
triangle Adoption
transparent gif
triangle General Risk Reduction for All Discordant Couples Trying to Conceive
transparent gif
triangle Risk Reduction When the Woman Is Infected and the Man Is Not
transparent gif
triangle Risk Reduction When the Man Is Infected and the Woman Is Not
transparent gif
triangle General Counseling Considerations for All Discordant Couples Trying to Conceive

transparent gif
References
transparent gif
transparent gif
transparent gif

Introduction

transparent gif

Providing reproductive counseling and care to HIV discordant couples (comprised of one sexual partner who is infected and one who is not) is complicated by economic, social, and cultural issues that include concerns about natural pregnancy vs adoption, child fostering, and the risk of transmitting HIV to the uninfected sexual partner.( 1 )

HIV-infected individuals usually are counseled to use condoms to prevent HIV transmission and to accept the reality that unprotected sex can result in HIV transmission to a sexual partner and, if pregnancy occurs, to the infant as well. Nevertheless, many discordant couples want to have children and request information on how to do so while minimizing HIV transmission to their partners and their infants. There are various options that health care providers can consider with clients based on their clinical judgment, but it must be cautioned that many of the recommendations are not supported by controlled clinical trials.

transparent gif

Counseling Concordant Couples

transparent gif

Use of antiretroviral drugs to treat the HIV-infected female partner and prevent infection of the infant
Women who require treatment for their own disease should receive combination antiretroviral treatment (ART) throughout pregnancy to reduce viral load, improve immune function, and reduce the risk of HIV transmission to the infant. Women who do not require ART to manage their own disease should receive antiretroviral (ARV) prophylaxis as early in gestation as possible (it is usually recommended to begin at 28 weeks' gestation). Their infants should receive ARV prophylaxis for 4 weeks after birth. The viral load during pregnancy is the main basis for estimating the likelihood that HIV transmission to the infant can be prevented. Undetectable viral loads are associated with mother-to-child transmission (MTCT) rates of <2%.( 2 )

Elective cesarean section further reduces HIV transmission during labor and delivery even when the viral load is undetectable. Complete avoidance of breast-feeding will prevent HIV transmission to the infant through breast milk. If replacement feeding is not possible for economic or safety reasons, exclusive breast-feeding with abrupt weaning at 6 months or earlier is recommended.

These percentages reflect statistical probabilities. Although the risk of perinatal HIV transmission is reduced from approximately 25% without treatment to < 2% with treatment, HIV transmission to the infant remains a possibility.

Superinfection/Reinfection
Superinfection (HIV infection of a previously infected individual with a different viral strain) is a concern when both the man and woman are infected. However, there is no data to suggest that a second viral strain would be less susceptible to ARVs used to prevent perinatal HIV transmission. Therefore, additional approaches to decreasing the risk of HIV transmission such as sperm washing and in vitro fertilization would appear to be unnecessary for concordant couples.

During counseling sessions, health care workers should address the following issues with clients:

  • The likelihood that they will survive long enough to effectively parent.

  • The possibility that the infant may become HIV infected.

  • The possibility of judgment and stigmatization by the community, health care workers, and family members.

  • For resource-poor settings, the lack of access to optimal treatment and monitoring to reduce the risk of HIV transmission.

transparent gif

Counseling Discordant Couples

transparent gif
transparent gif

Adoption

transparent gif

Adopting or fostering a child should be encouraged as the most viable option to meet the needs of orphaned children in the community and the need of an HIV discordant couple to parent while reducing the risk of HIV transmission.

If a HIV discordant couple has a strong desire to have a child of their own, several other options are available. However, it should be emphasized that all carry varying degrees of risk of HIV transmission either to the sexual partner or to the infant.

transparent gif

General Risk Reduction for All Discordant Couples Trying to Conceive

transparent gif

Health care workers should:

  • Screen for and treat sexually transmitted infections.

  • Counsel couples to have sex only when they are sure the woman is in the fertile period of her cycle. Using an ovulation indicator kit can help to pinpoint this time.

  • Counsel couples to stop having unprotected sex as soon as pregnancy occurs.

  • Counsel couples to avoid using products such as douches or herbs that will irritate the genital tract. Practices such as dry sex should also be avoided.

transparent gif

Risk Reduction When the Woman Is Infected and the Man Is Not

transparent gif

Reducing the risk of HIV transmission from the HIV-infected female partner to the uninfected male partner
ART can result in undetectable viral loads and restoration of the immune system. Clinical studies suggest that treatment of HIV with ART reduces the risk of HIV transmission during unprotected sex.( 3 ) However, it should be made clear that the risk is reduced but not eliminated. Control of HIV infection also may increase the probability of pregnancy for an HIV-infected woman.

It is possible to further reduce the risk of transmission to the male, uninfected sexual partner by using ARVs for postexposure prophylaxis in a manner similar to that used for prevention of HIV transmission to health care workers exposed to HIV by accidental inoculation.( 4 ) Postexposure ARV prophylaxis also has been used following rape and currently is being evaluated in studies of commercial sex workers. Combination ARVs for postexposure prophylaxis usually are administered for 4 weeks following accidental or sexual exposure. The use of ARVs for postsexual exposure other than rape is controversial. Preexposure prophylaxis using tenofovir also has been posited as a possible risk reduction measure, although trials on its effectiveness are just beginning.( 5 )

Reducing the risk of transmission to the infant
The measures to reduce the risk of MTCT are the same as those outlined above for concordant couples.

transparent gif

Risk Reduction When the Man Is Infected and the Woman Is Not

transparent gif

Reducing the risk of HIV transmission from the HIV-infected male partner to the uninfected female partner
As discussed above, ART reduces the viral load, improves the immune system, and reduces the likelihood of HIV transmission to an uninfected sexual partner. The potential for HIV transmission is not eliminated but merely reduced. This is the only option currently available to a discordant couple living in a resource-constrained setting that wishes to have a child while reducing the risk of HIV transmission.

Sperm washing and insemination
Sperm washing is performed when there is a strong desire for the discordant couple to conceive their own child or when there are religious, ethical, or legal constraints that prevent the use of an unrelated donor. Sperm washing has been evaluated for more than 10 years with more than 240 reported cases of artificial insemination resulting in pregnancy.( 6 ) The basis for this approach is the observation that sperm lack CD4 receptors and that CD4 cells containing HIV are removed during the washing. Testing the sperm for HIV using polymerase chain reaction (PCR) assays after washing is an additional safety measure.

The procedure is complicated by the necessity of implanting the washed sperm directly into the endometrial cavity. In most settings, the procedure is expensive and is associated with legal, ethical, and liability issues. A modification of sperm washing uses intracytoplasmic sperm injection and in vitro fertilization, which limits viral exposure to fewer motile donor sperm cells.( 6 ) Postexposure prophylaxis following artificial insemination could further reduce the possibility of HIV transmission to the uninfected female partner. However, there are no controlled trials using this approach and nothing is known concerning the potential effect of ARVs on the fertilization process or subsequent fetal development.

Artificial insemination using a non-HIV-infected donor
If an unrelated sperm donor is used for insemination, it is recommended that HIV testing be performed on 2 occasions: at initial screening and following a 3- to 6-month period during which the donor should avoid potential exposure to HIV.( 1 ) The donor should be tested using both antibody-based testing and PCR techniques. Whereas using an unrelated donor offers the safest approach to pregnancy for an HIV-uninfected woman, it is most often associated with religious and legal issues.

transparent gif

General Counseling Considerations for All Discordant Couples Trying to Conceive

transparent gif

During counseling sessions, health care workers should address the following issues with clients:

  • The couples' concerns about the HIV-uninfected partner's risk of becoming infected.

  • The likelihood that the HIV-infected partner will survive long enough to effectively parent.

  • The possibility that the infant may become HIV infected.

  • The possibility of judgment and stigmatization by the community, health care workers, and family members.

  • Lack of up-to-date knowledge on the risks of HIV transmission to partners under the various scenarios.

  • For resource-poor settings, the lack of access to optimal treatment and monitoring to reduce the risk of HIV transmission.

  • For resource-poor settings, the excessive cost of specialized procedures that may be required.

  • For resource-rich settings, the legal aspects of artificial insemination using either the sexual partner or an unrelated donor.

transparent gif

References

transparent gif
1. transparent gif Ethics Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine. Human immunodeficiency virus and infertility treatment. Fertil Steril. 2004 Sep;82 Suppl 1:S228-31.
transparent gif
2. transparent gif Ioannidis JP, Abrams EJ, Ammann A, et al. Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads < 1000 copies/ml. J Infect Dis. 2001 Feb 15;183(4):539-45. Epub 2001 Jan 12.
transparent gif
3. transparent gif McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. J Antimicrob Chemother. 2006 Feb;57(2):163-6. Epub 2005 Dec 6.
transparent gif
4. transparent gif Winston A, McAllister J, Amin J, et al. The use of a triple nucleoside-nucleotide regimen for nonoccupational HIV post-exposure prophylaxis. HIV Med. 2005 May;6(3):191-7.
transparent gif
5. transparent gif Vernazza PL, Hollander L, Semprini AE, et al. HIV-discordant couples and parenthood: how are we dealing with the risk of transmission? AIDS. 2006 Feb 28;20(4):635-636.
transparent gif
6. transparent gif Sauer MV, Denison R, Rankin T, et al. Roundtable discussion. J Acquir Immune Defic Syndr. 2005 Mar;38 Suppl 1:S39-45.
transparent gif
transparent gif
space
transparent gif