Wendy from NSW writes:
We are a discordant couple (my husband is positive and I am not) and we would like to have a baby. What are our options?
Dr Louise replies:
This is a tricky area, Wendy, and I thank you for raising it.
Firstly, we would recommend that your husband is on HAART and has a fully suppressed viral load.
We know that transmission of HIV can occur in unprotected vaginal intercourse at a rate of about one in 1000 sexual encounters.
However, other factors which increase the risk of transmission include inflammatory conditions, such as untreated or undiagnosed STIs and ulcerative conditions in either partner.
Also, viral load in seminal fluid doesn’t always correlate with blood viral load . So, even when HAART has fully suppressed viral load in the blood, HIV may still be found in the semen and the seminal fluids. This is why we recommend continuing to use condoms for sexual intercourse.
To date, we don’t have enough data available on the use of Pre Exposure Prophylaxis (PrEP) in this setting, so we need to wait for further information.
Some couples accept the small but real risk of HIV transmission to the female partner and choose to have unprotected intercourse at the time around ovulation.
Your GP can give you information regarding signs of ovulation and cycle information.
For some couples, pregnancy occurs quite quickly. For others, however, even when both partners are fertile and ovulation does occur, pregnancy does not always follow.
Other couples utilise various assisted reproduction techniques (ART) to decrease the risk of HIV transmission.
ARTs use a technique called sperm washing, where the semen is placed in a centrifuge and spun, thus separating the sperm from the seminal fluid. At some centres, the washed sperm then goes through HIV RNA testing, but this is a very specialised and expensive technique.
In vitro fertilisation (IVF) is where conception takes place outside the woman’s body allowing incubation to occur in the test tube.
Intracytoplasmic sperm injection (ICSI) is where one single sperm is injected into the egg. This is usually used in situations of male infertility.
There is also intrauterine insemination where some of the washed sperm are placed into the uterus with a soft, pliable catheter. This is a risk-reduction procedure and not completely risk free.
All of these techniques are expensive, invasive and only available at certain tertiary level centres in some cities.
The good news is that there are many reports from international ART clinics where inseminations have occurred in discordant couples without one documented case of seroconversion.
It is important where possible to start planning the pregnancy and workup well in advance. This will give you enough time to plan the pregnancy: checking your partner’s general health, rubella status, your preparedness for pregnancy (which may include taking folate supplements) and to work out your ovulation cycles.
All this will enhance the planning of timing of intercourse or intervention to correlate with ovulation.
Then we would recommend your HIV doctor contact your specialist centres to see what is available in your area.
Special thanks to Michelle Giles for her help reviewing the facts for this letter.
Dr Louise Owen’s advice is not meant to replace or refute any advice given by your own doctor as your individual medical circumstances are best dealt with by your own practitioner.