Natural Conception May Be an Acceptable Option in HIV-Serodiscordant Couples in Resource Limited Settings

Experiences With Safer Conception Services for HIV-Serodiscordant Couples at a Referral Hospital in Nairobi, Kenya

Human immunodeficiency virus-serodiscordant couples are an important source of new HIV infections in Africa. When trying to conceive, uninfected partners may be at high risk of infection if the infected partner is not virally suppressed. Multiple strategies targeting safer conception exist, but these services are limited. However, when services are available and used, serodiscordant couples can be protected from HIV transmission, and safe to have children if desired. To successfully introduce, integrate, promote, and optimize the service delivery of safer conception with HIV care, it is crucial to understand how HIV-serodiscordant couples perceive and experience these services. Further, viral load monitoring can be critical to safer conception, but there is limited literature on how it informs the decision of the partners about conception. This qualitative study describes the knowledge, perceptions, and experiences of both safer conception services and viral load monitoring among 26 HIV-serodiscordant couples seeking safer conception care at a referral hospital in Nairobi, Kenya. In-depth interviews of HIV-serodiscordant couples were conducted from April to July 2017, and transcripts were analyzed to identify the themes central to the experience of safer conception services of couples and viral load monitoring. Serodiscordant couples reported success in using some of the safer conception methods and had positive experiences with healthcare providers. However, despite using the services, some were concerned about HIV transmission to the seronegative partner and baby, while others faced challenges when using pre-exposure prophylaxis (PrEP) and vaginal insemination. Overall, their motivation to have children overcame their concern about HIV transmission, and they welcomed discussions on risk reduction. Moreover, supportive clinic staff was identified as key to facilitating trust in safer conception methods. Furthermore, viral load monitoring was identified as integral to safer conception methods, an emerging theme that requires further evaluation, especially where routine viral load monitoring is not performed. In conclusion, healthcare providers offering safer conception services should build trust with couples, and recognize the need for continual couple counseling to encourage the adoption of safer conception services.

Living with Discordance: A Qualitative Description of the Challenges Faced by HIV Negative Married Women

Background:

Serodiscordant couples are faced with many social, sexual and relationship challenges in all aspects of their lives. The sources of conflicts could be disease acquisition, transfer of HIV to the uninfected partner, and fertility decisions. The current qualitative study was designed to explore the challenges faced by HIV negative women in serodiscordant relationships.

Methods:

This qualitative description was conducted in Mashhad, Northeast of Iran, between October 2018 and June 2019. 15 HIV-negative women who were living with their HIV-positive husbands were selected through purposive sampling method. The data were collected using semi-structured interviews. Data were analyzed using conventional content analysis adopted by Graneheim and Lundman. MAXQDA version 12, was used for data organization. Components of rigor including credibility, dependability, confirmability and transferability were considered.

Results:

The main overarching theme which emerged from the qualitative study was “threats to family life”, consisting of five categories along with their subcategories. These categories included stigmatic reactions followed by disclosure of the status, social misconceptions and limitation of information sources, psychological disruptions, hard decision making for fertility, and role conflict in the family.

Conclusion:

This study provides an insight into different aspects of challenges faced by Iranian women in HIV-serodiscordant relationships. Also, our study supports the view of other investigators who believe that there is an urgent need for provision of counseling and empowerment interventions for HIV- serodiscordant couples.

Is PrEP necessary during natural conception in HIV-1-serodiscordant couples on ART with suppressed viral load? A retrospective cohort analysis

Background

Antiretroviral therapy (ART) demonstrates high efficacy in reducing the risk of HIV transmission to sexual partners. However, it is not clear if the use of pre-exposure prophylaxis (PrEP) in HIV-1-serodiscordant couples is necessary during natural conception when the HIV-positive partner exhibits a suppressed viral load. The purpose of this study was to assess the role of PrEP during natural conception in this population.

Methods

A retrospective, multicenter study was conducted in a cohort of HIV-1-serodiscordant couples (positive man, negative woman) with childbearing desires. HIV-positive male partners were treated with ART and achieved viral suppression for more than half a year. The HIV-negative female partners were either treated with PrEP or not treated with PrEP, and outcomes were compared between the two treatment groups.

Results

Of 246 HIV-1-serodiscordant couples in whom the HIV-positive partner achieved viral suppression, 104 seronegative women were treated with PrEP during natural conception and 142 seronegative women were not treated with PrEP. There were 410 condom-less sexual acts in couples treated with PrEP and 615 condom-less sexual acts in couples not treated with PrEP. We observed no instances of HIV transmission in HIV-1-serodiscordant couples with or without the use of PrEP during the process of natural conception.

Conclusions

Our results show that PrEP had minimal influence in reducing the risk of HIV transmission during natural conception in HIV-1-serodiscordant couples with a stably suppressed viral load. Thus, it may be an acceptable option for HIV-negative partners to not use PrEP during the process of natural conception if the HIV-positive partner has achieved viral suppression for more than half a year.

Natural Conception is Safe for HIV-Serodiscordant Couples with Persistent Suppressive Antiretroviral Therapy for the Infected Partner

Background: Sustained use of antiretroviral treatment to achieve a suppressed viral load in persons living with HIV is associated with zero or near-zero risk of sexual and vertical HIV transmission. This has led to an increasing number of HIV-serodiscordant couples (SDCs) who wish to have children. The aim of this study was to describe the most recent results of a protocol for reproductive counseling directed at HIV-SDCs who desire natural conception and to identify some of the factors influencing reproductive success. Methods: Two hundred fourteen couples were enrolled. Sociodemographic/behavioral and clinical data were collected. CD4+ lymphocyte count, HIV viral load, serology/viral load of hepatitis B/C viruses, syphilis serology, and other sexually transmitted infection diagnosis in both members of couple; spermiogram in men, HIV proviral and viral load in semen of male HIV-infected partners, and urine luteinizing hormone qualitative test in women were performed. Unprotected vaginal intercourses, pregnancies achieved, and their outcomes were recorded. Results: After almost 10,000 sexual relations, a total of 188 pregnancies was achieved, 62% of couples became pregnant once or several times with no HIV transmission to either the partner or the offspring. Younger age of woman, no fertility disorders in both members of couple, and no treatment with efavirenz in men were factors related with reproductive success. Conclusions: Natural conception, under controlled conditions, can be offered to SDCs who wish to have children as a safe method of conception and its effectiveness seems to be related to factors not different from those of the general population.

Fertility care interventions should be provided as the first line options for HIV+ serodiscordant couples who desire children in settings with affordable access to care, regardless of their fertility status

INTRODUCTION

With increasing life expectancy, couples with at least one partner afflicted with HIV are more commonly pursuing the opportunity to have biologic offspring. Currently, there are no universally accepted recommendations regarding first line reproductive treatments for HIV serodiscordant couples lacking a history of infertility. We strongly believe that fertility care intervention should be the first line treatment, when affordably accessible, over natural conception for HIV serodiscordant couples to achieve pregnancy in a safe and efficacious manner.

Discussion

In the era of highly active anti-retroviral therapy, in combination with timed intercourse and pre-exposure prophylaxis for the HIV negative partner, some members of the medical community are arguing in favour of natural conception as a means of achieving pregnancy in this patient population. In our opinion, laboratory assisted fertility methods, including intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection with semen washing should be the first line treatment recommendation for HIV serodiscordant couples desiring pregnancy for the following reasons: (1) abundance of evidence in the medical literature supporting the safety profile and efficacy of fertility care intervention in couples with HIV; paucity of data addressing safety of natural conception in comparison to fertility intervention techniques (2) unknown public health impact of promoting natural conception as a safe means of achieving pregnancy (3) ethical implications: patients should be offered the available and accessible treatment option posing the lowest possible known risk to the uninfected partner.

Conclusions

We believe that physician assisted fertility care, when affordably accessible, should be the treatment of choice over natural conception. While the preliminary data on natural conception in couples using highly active anti-retroviral therapy/pre-exposure prophylaxis/timed intercourse appears promising, we believe that this approach should be limited to patients in resource poor settings where more sophisticated measures do not exist or for patients that simply cannot afford subspecialty care. There are likely to be unknown psychological and behavioural factors impacted by promoting natural conception and diminishing the importance of safe sex practices. Additionally, it is our moral obligation to patients to offer the affordably accessible treatment interventions that pose the least known risk when considering reproductive options.

Natural conception in HIV-serodiscordant couples with the infected partner in suppressive antiretroviral therapy: A prospective cohort study

The potential of antiretroviral treatment (ART) to prevent the sexual transmission of HIV has increased the number of serodiscordant couples who are considering natural conception. We aim to describe the results of a protocol for reproductive counseling aimed at HIV serodiscordant couples who desire natural conception, in which the infected partner, the index case, is receiving suppressive antiretroviral treatment.A prospective cohort included all HIV serodiscordant couples attended a counseling program in the period 2002 to 2013 who opted for natural conception and met the following criteria: index case on ART with persistent plasma viral suppression for at least the previous 6 months, ART compliance over 95%, preserved immune status, undetectable HIV viral and proviral load in semen in male index cases, and absence of genitourinary infections and fertility problems in both members of the couple.Of the 161 HIV serodiscordant couples included, 133 with male index cases, 66% achieved at least 1 pregnancy, 18% a second one, and 5% a third pregnancy. A total of 144 natural pregnancies occurred and 107 babies were born. The pregnancy rate was 1.9 for each 100 acts of vaginal intercourse, and the mean time to conception was 6.1 months, both independently of the sex of the index case. No case of sexual or vertical HIV transmission occurred.In the absence of fertility problems and under controlled conditions, natural conception might be a safe and effective reproductive method for those HIV serodiscordant couples who choose this reproductive option.