husband viral load <20,CD4 687 Wife's viral load 18115 and CD4 673. The woman is NOT on antiretrovirals. How do we advise the couple?

In this case, the major concerns would be to optimize maternal health in order to optimize the chance of a healthy baby and to minimize the risk that mom will transmit HIV to the baby. While current guidelines do not recommend therapy for a non-pregnant woman with these CD4 and RNA levels for her own health, most experts would recommend the initiation of antiretroviral therapy to maximize the control of viral replication and minimize the risk of HIV transmissioni to the baby. Ideally, this would be started prior to pregnancy to optimize maternal health and to be sure that mom is tolerating the medications well. Resistance testing should be done to help guide the selection of appropriate antiretroviral agents. There is a lot of information on this web site that can help you and the couple plan for a pregnancy. The "Guidelines for the Use of Antiretroviral Agents in Pregnancy" (available under the "Treatment Guidelines" section) provides an excellent overview of mother-to-child HIV transmission and how to prevent it. There are also past questions/answers on this forum that may help. Finally, there is a very helpful discussion of this topic that was recently published in the New England Journal of Medicine (Riley and Yawetz , New England Journal of Medicine, 353: 1725, 2005).