How Do I Help Serodifferent Couples Safely Conceive?

Providing options for safer conception is an essential part of delivering integrated HIV care and prevention. Steps for safer conception counseling are described below:

Discuss the role of antiretroviral treatment (ART) and maintaining a durably suppressed viral load (viral load remains undetectable for at least six months after their first undetectable test result) in preventing sexual and perinatal HIV transmission

Consider potential barriers and possible solutions to maximize adherence to ART

Discuss optimizing general health prior to conception

Consider potential barriers and possible solutions to maximize adherence to ART
Treat/manage other acute or chronic conditions
Screen/treat both partners for sexually transmitted infections
Achieve and maintain a healthy activity level, weight, and diet
Stop smoking and avoid second-hand smoke
Treat substance or alcohol abuse, if applicable
Ensure immunizations are up to date. For information about immunizations and pregnancy, see: http://www.cdc.gov/vaccines/pubs/preg-guide.htm

Recommend multivitamins with 400 mcg of folic acid daily
Consult your primary care provider before taking over the counter medicines and avoid alcohol
Check for safety of medications in pregnancy See: Mother to Baby http://www.mothertobaby.org/ or call 1-866-626-6847
Refer for preconception obstetrical evaluation

Order semen analysis for males with HIV. HIV infection, and possibly ART, may be associated with a higher prevalence of semen abnormalities. If abnormalities are present, the female without HIV may be exposed unnecessarily to HIV when the likelihood of getting pregnant is low or nonexistent.

Discuss additional conception options

Effective ART with sustained viral suppression in the partner with HIV can make conceiving a baby very safe. Some couples may choose to use additional prevention strategies, particularly if the partner with HIV is not virally suppressed or viral load is unknown. It is important for providers to discuss available options in addition to ART to help couples decide what is best for their families.

Timed condomless intercourse: Timed, periovulatory, condomless intercourse after the partner with HIV has achieved viral suppression may further reduce the risk of sexual transmission. Partners have condomless sex during ovulation (+/- 1 or 2 days) for the purpose of conception but choose to use condoms at all other times. Counsel couples on how to predict ovulation (calendar method) or test for ovulation using an ovulation kit.
Timed, condomless intercourse with pre-exposure prophylaxis (PrEP) for the partner without HIV: The partner without HIV can choose to take PrEP, a combination pill of tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC, brand name Truvada®). Male partners can also take emtricitabine plus tenofovir alafenamide (TAF, brand name Descovy®) and cabotegravir injectables (CAB, brand name Apretude®). Use of PrEP during the periconception period by the partner without HIV may offer an additional tool to help reduce the risk of sexual HIV acquisition. Both the Food and Drug Administration labeling information and the perinatal antiretroviral treatment guidelines permit the use of TDF/ FTC during pregnancy. The efficacy of TDF/FTC for HIV prevention is highly dependent on adherence to daily doses of medication. Prescriptions for TDF/FTC are usually fully or partially covered by public and private insurance plans. For persons who are uninsured or those with inadequate insurance coverage, information about the manufacturer’s PrEP Medication Assistance Program is available at: http://www.gilead.com/responsibility/us-patient-access.
Adoption: Adoption is arranged by state child welfare agencies or by private agencies under contract with states. Adoption is also available through state foster care systems. The Americans with Disabilities Act of 1996 prohibits discrimination based on HIV infection.
Surrogacy: There are complicated medical, ethical, and psychologic aspects to surrogacy and legal statutes related to surrogacy vary widely by state. Refer individuals or couples interested in surrogacy for counseling by an experienced and knowledgeable provider.

Self-insemination: The man ejaculates fresh semen into a clean container or condom and has no exposure risk. A needleless syringe is used by the woman or her partner to insert semen into the upper vagina. Most effective if performed during ovulation (+/-1 or 2 days). Counsel on how to predict ovulation (calendar method) or test for ovulation using an ovulation kit.
Insemination by a fertility specialist: Fresh sperm is inserted into the woman’s vagina or uterus by a trained specialist at a fertility clinic. This procedure may not
be covered by public or private insurance plans.
Artificial insemination: (self-insemination or insemination by a fertility specialist) with donor sperm from a man without HIV is also a safe option.

Artificial insemination:

Sperm washing + artificial insemination: Sperm washing is the process by which individual sperm are separated from the seminal fluid. The sperm are then used for insemination. Sperm washing with insemination substantially and significantly reduces the risk of HIV transmission. It can be used to decrease the risk of HIV transmission to an uninfected female recipient because HIV is carried by the seminal fluid rather than the sperm. This procedure is often not covered by public or private insurance plans. The value of combining sperm washing and artificial insemination with durable suppression of HIV in the male partner is unknown; both sperm washing and ART with sustained viral suppression substantially and significantly reduce the risk of transmitting HIV.
Donor sperm: Sperm donation is the provision of sperm by a man without HIV for the purpose of inseminating a woman who is not necessarily his sexual partner. Typically, sperm is donated through a sperm bank or fertility clinic where a number of steps are taken to ensure the health and quality of the sperm and legal rights to future children are relinquished. Private arrangements for sperm donation do not have the same health or legal protections

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