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Guide to HIV, Pregnancy and Women's Health: Planning Your Pregnancy

By Polly Clayden

March 2013

Many HIV positive women become pregnant when they already know their HIV status.

Many women are also already taking ART when they become pregnant. If you already know that you are HIV positive, you may have discussed the possibility of becoming pregnant as part of your routine HIV care -- whether this pregnancy was planned or not.

If you are planning to get pregnant, your healthcare provider will advise you to:

You should also make sure you are receiving appropriate care and treatment for your HIV. It is reassuring that over 98 percent of HIV positive pregnant women have uninfected babies in the UK currently.

Choose a healthcare team and maternity hospital that supports and respects your decision to have a baby.

In this section, as well as options for HIV positive women (with either negative or positive partners) wishing to get pregnant, we look at safer conception for HIV negative women with HIV positive partners.


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Timing of Conception Attempt

Ovulation -- the most fertile time during a woman's menstrual cycle is when a mature egg is released from her ovary. The egg has a life span of about 24 hours. Conception is most likely to take place at this time.

Ovulation takes place about 14 days before the beginning of the woman's next menstrual cycle.

You are at your most fertile time the day before and the day of ovulation as the egg survives about 24 hours. This is when conception can take place.

The fertile period is usually about 5 days before ovulation (as sperm can survive in your body for several days) until about 2 days after ovulation. So the period that a woman is fertile is about 7 days.

There are different ways to estimate your fertile time, usually by taking your temperature (which increases at the beginning of ovulation), or by recording when you have your periods, in order to work out when you are ovulating (called the calendar method). Chemists sell ovulatory kits that can help you work this out.

Your healthcare team can explain to you how to do this.


Pre-Exposure Prophylaxis (PrEP)

This is when an HIV negative person takes antiretrovirals to prevent them from getting HIV. This method is sometimes recommended to help make a conception safer.


What to Do When One Partner Is HIV Positive and the Other Is HIV Negative

Recently there has been good news for couples in this situation.

In January 2013, BHIVA and the Expert Advisory Group on AIDS (EAGA) issued a position statement on the use of ART by HIV positive people to reduce HIV transmission.

The statement refers to a very large study that in 2011 reported some very important news. The results from the HIV Prevention Trials Network (HPTN) Study 052 provided proof that ART can make HIV positive people less infectious to their HIV negative partners.

The study was conducted in several countries with over 1700 couples where one partner was HIV positive and the other HIV negative. It compared the effect of starting ART immediately (CD4 count between 350 and 550) to delaying starting until the positive partner reached a CD4 count of less than 250.

The results showed that starting ART at higher CD4 counts lowered the risk of HIV transmission by a remarkable 96 percent. The study was stopped early as the benefits were shown more quickly than anticipated in the original design.

The BHIVA/EAGA statement notes that successful ART use by the HIV positive person is as effective as consistent condom use in limiting transmission.

Importantly, it stresses that this is provided the following conditions are met:

Health care professionals in the UK are recommended to discuss the impact of ART on transmission with HIV positive people and the possibility of starting ART for this purpose.

You can find the position statement on the Department of Health website.

Also in January 2013 a systematic review (when all the published research on a topic is looked at all together in order to answer a question) was presented of publications reporting rates of HIV transmission in heterosexual couples, when the positive partner had an undetectable viral load. This review included results from HPTN 052 an also found a minimum risk of transmission.

For many people these developments are very reassuring, particularly those who meet the ART and viral load conditions and choose to have sex without condoms.

Couples who generally use condoms will be advised that the recommended way of conception is by timed intercourse when the woman is most fertile. Sometimes the negative partner will be recommended to take PrEP.

Occasionally some couples might still be anxious about transmission with unprotected intercourse even though they meet the ART, adherence and viral load conditions. Or they might not meet the conditions. In these cases they might be recommended and consider other methods.

When the Man Is HIV-Positive and the Woman HIV-Negative

When the man is HIV positive with a negative partner, it is possible to use a process called sperm washing. This involves the man giving a semen sample to a clinic.

A special machine then spins this sample to separate the sperm cells from the seminal fluid. (Only the seminal fluid contains HIV; sperm cells themselves do not carry HIV).

The washed sperm is then tested for HIV.

Finally, a catheter is used to inject the sperm into the woman's uterus. In vitro fertilisation (IVF) may also be used, especially if the man has a low sperm count.

There have been no cases of HIV transmission to women from sperm washing.

I am HIV positive. My partner is HIV negative. We have two beautiful daughters. Both conceived naturally. Both, like their mum, are HIV negative

We initially considered sperm washing, but we would have needed to use artificial insemination. This was extremely expensive and involved travelling and giving my partner hormone injections.

This was not the way we wanted to have a baby.

We decided that the risk of transmission with someone who was undetectable for many years, extremely adherent and had no STIs was very low.

So we bought a cheap ovulation test and did it naturally ... and it worked ... twice!

-- Mauro, Italy

Very few clinics offer this service in the UK but the clinic with the most experience is the Chelsea and Westminster Hospital in London. The Chelsea and Westminster assisted conception unit can be contacted on 0208 746 8585. It is not always possible to obtain this procedure on the NHS.

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Apart from the costs, one of the disadvantages of sperm washing is that is does not have a very high success rate for conception, compared to conceiving by having sex. It is very safe in far as preventing HIV transmission is concerned, but it also means you will be conceiving your baby in a very medicalised environment. Many people find this difficult, especially if it does not lead to a successful pregnancy.

As the information about safe conception protected by ART makes it more acceptable for couples to use this method of conception, sperm washing is being recommended and used less and less.

Of note the National Institute of Clinical Excellence (NICE) 2011 draft fertility guidelines include a section on viral transmission with the question: "What is the effectiveness and safety of sperm washing to reduce the risk of viral transmission?" It specifically looks at transmission risk of HIV when HIV positive male partners are on treatment.

It concludes that generally recommendations should be ART- protected intercourse. Where these conditions are not met couples would still be advised to have sperm washing. It acknowledges that there might be some couples who would still request sperm washing, despite the HIV positive man being adherent on ART with a viral load of less than 50 copies/mL. For this they recommend that the request should be considered.

In situations where ART is being used and viral load is undetectable the guidance explains that sperm washing only reduces viral load rather than eliminating it, so there would be little or no added benefit from this option.

The guidance is here.


When the Woman Is HIV Positive and the Man Is HIV Negative

The options are much simpler and cheaper in this situation. Do-it- yourself artificial insemination (self insemination) using a plastic syringe carries no risk to the man.

This is a very safe way to protect the man from HIV.

Around the time of ovulation, you need to put the sperm of your partner as high as possible into your vagina. Ovulation takes place in the middle of your cycle, about 14 days before your period.

Different clinics may recommend different methods. One way is to have intercourse with a spermicide-free condom. Another is for your partner to ejaculate into a container. In both cases, you then insert the sperm into your vagina
 with a syringe.

Your clinic can provide the container and syringe. They can also give detailed instructions on how to do this, including advice on timing the process to coincide with your ovulation.

I have lived with HIV for so long that I don't remember what it's like to live without it. I found it difficult to be HIV positive in the beginning. But once I learned to live with it, I decided to start living my life again.

I then realised I could do all the things that I thought HIV made impossible. I though I could not live over 25 years, or ever have a successful relationship or have children!

So last year I told my partner, who is HIV-negative, that I would love to have a child and he agreed.

We talked about how to achieve this and the possible options. We settled on the least complicated option -- unprotected sex during my ovulation period. In a couple of months, I conceived!

My pregnancy was relatively easy. My obstetrician strongly advised that I go for a vaginal delivery as my CD4 was very good and my viral load undetectable.

My baby was tested for HIV a day after he was born. He has now had several negative results. He is now 6 months old and growing beautifully.

My partner remains HIV negative.

-- Millie, Bristol


When Both Partners Are HIV-Positive

For couples in which both partners are HIV positive, some doctors, in some cases, still recommend sex with condoms to limit the possibility of re-infection with a different strain of HIV (or a resistant strain).

Re-infection is only a risk if one partner has extensive drug resistance and a detectable viral load, or neither partner is on ART. This should be the only reason that a couple in this situation should be discouraged to attempt to conceive naturally.

All these options involve very personal decisions. Knowing and judging the level of risk is also very individual. All methods of becoming pregnant carry varying degrees of risk, and chance of success (and sperm washing and fertility treatment may involve a cost if you are unable to access them on the NHS).

If you are planning a pregnancy, take the time to talk about these options with your partner. This way you can make decisions that you both are happy with.


Can I Get Help If I Am Having Difficulty Conceiving?

All couples could experience some fertility difficulties, regardless of who is HIV positive or if both are.

There are things you can do, though, which have all had some success. But sometimes they are not as easy as they sound.

If you have fertility problems, ask your doctor about assisted reproduction. Ask about the possibility of referral to a fertility clinic with experience of HIV.


Is Fertility Treatment Available to HIV Positive People?

Yes. Fertility is important when trying for a baby whether or not you are HIV positive.

The same fertility support services should be provided for HIV positive people as for HIV negative people.

There will also be the same levels (which can be quite strict) of screening given to you as any couple accessing fertility treatment. Sometimes this will not be available on the NHS.

You may encounter resistance to this help because you are HIV positive. You can and should complain about this if you do.

You may want to choose a clinic that is more sympathetic, or perhaps a clinic that has more experience with HIV positive parents.


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This article was provided by HIV i-Base. It is a part of the publication Guide to HIV, Pregnancy and Women's Health. You can find this article online by typing this address into your Web browser:
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