Having a Baby When You Have HIV
This method protects either partner from getting HIV through sex. Most experts agree that HIV does not infect sperm cells. That makes it possible to use the sperm removed from the semen of a man with HIV safely. Two methods are most commonly used. In "density-gradient centrifugation" a sperm sample is mixed with a nutrient medium in a test tube and spun in a high-speed centrifuge. Sperm end up in the bottom layer of liquid and other cells which might be infected, remain in the upper layer.
This method can be further enhanced by the "swim-up technique". The washed sperm are placed in a petri dish and covered with culture medium (a liquid used to keep cells alive). Only the healthiest sperm swim into the medium, leaving other cells and HIV behind.
But at least six states have laws preventing the use of sperm from men with HIV in artificial reproductive techniques. Even in states without such laws, some clinics may refuse to provide services to people with HIV, but people should continue to investigate reputable health care facilities.
Once the sperm have been separated from the semen, they must be placed in the vagina. Known as insemination, this can be done either by a doctor or at home. If done by a clinic, the cost is about $300 to $500 or higher per attempt. Since many couples can't afford that, some do it themselves. Sometimes called the "turkey baster" method, this should be done when the woman is ovulating (ovulation tests are available without a prescription).
- Get a plastic syringe from your doctor or buy the kind used to give medicine to babies. Draw back on the syringe once with nothing but air, then push the air out again. Now point the syringe into the sperm sample and slowly draw it back to suck in the liquid.
- Get into a comfortable position, either lying on the bed with your bottom raised on a cushion, or on your hands and knees.
- Either you or your partner slowly inserts the syringe as far into the vagina as possible. The area to aim for is high up in the vagina, toward the cervix.
- Slowly squirt out the contents of the syringe and remove it gently.
- Lie down for the next 30 minutes while the sperm make their way through the cervix. Some semen may leak out, but this is normal.
If you have difficulty in conceiving or if your partner has a low sperm count, couples can opt to try in vitro fertilization (IVF) together with sperm washing. IVF entails removing eggs from the woman and fertilizing them with the man's sperm in the laboratory. The fertilized egg is then implanted in the woman. It's considerably more expensive than insemination: over $6,000 per cycle. The success rate after sperm washing is about the same as it is for HIV-negative semen: around 12% for insemination and just over 30% for IVF.
Taking Off the Condoms
All of the above methods have been tested and are generally accepted by the medical community. But what about unapproved methods, like just taking off the condoms? This is the unspoken reality for many couples. Many doctors will not publicly discuss it due to the risk of transmission. In fact, one advocate with knowledge of this practice refused to be publicly interviewed for this article due to fears it would lead to his program's funding being cut.
But couples certainly are doing this, as noted in this forum post from a man who identifies himself only as Mauro:
"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!"
An unnamed woman wrote this at thebody.com:
"My husband is positive, I am negative. I have contacted local labs to see whether they could help with sperm washing but have not had any luck. The only way is to pay over $3000 to send the sperm overnight to a facility that will process the sperm and check if it is undetectable and have it sent back, then an additional $10,000+ for IVF. Since this is not an option -- next cycle I will use HIV meds and take my chances. I think it is really sad that there are so many of us wanting to have a child so badly that we are willing to put ourselves at risk. I feel I am playing Russian Roulette with my life and wish I could find an alternative solution to this."
In Italy, Enrico Semprini was one of the first to promote artificial insemination for serodiscordant couples. But according to Pietro Vernazza, of Switzerland's Cantonal Hospital, "about one third of the women who came for the first consultation would never show up for an insemination. And within Europe, all the centers have about one third noshows -- people who just don't follow up. Semprini followed up with them. And among the 500 couples, 250 are parents now ... We were sort of accepting that a major group was taking the risk and having unprotected sex. So we thought: It's okay. The risk is very, very low. It's probably in the range of one in 100,000, or one in one million. That's about the risk that you take when you mount an airplane."
To lower the risk as much as possible, Vernazza recommends these steps:
- Having unprotected sex only when the woman is ovulating
- Testing for STIs, which increase the risk of HIV transmission
- Ensuring that the positive partner is on a stable regimen with an undetectable viral load for at least six months
- Prescribing PrEP for the negative partner -- usually Truvada (he has used two doses)
His study of 53 couples in which the man was HIV positive reported pregnancy rates of 50-75%, depending on the number of attempts. According to Vernazza, "It's certainly better than with the insemination practice, where we reach 40%." None of the women in the study were infected.
Much of the impetus for couples taking off the condoms comes from a study known as HPTN 052. It enrolled 1,763 couples (97% heterosexual) in which one partner, the man or the woman, had HIV, was not taking HIV meds, and had a CD4 count between 350 and 500. Half of the positive people in the study began HIV meds immediately, and half waited until the CD4 count dropped below 250.
The study was meant to run five years, but was stopped early due to the dramatic results. Of the 28 cases of HIV transmission in the study, 27 occurred in those who delayed treatment. That means that starting HIV treatment early reduced the risk of transmission by 96%. That's definitely lower -- but it's not zero.
In Madrid, Pablo Barreiro looked back at 74 serodiscordant couples (52 with positive men and 22 with positive women). They were advised to have intercourse only when the woman was ovulating, and only after the partner with HIV had an undetectable viral load for six months. 75 children were born, and no cases of HIV transmission to the partner or child were reported. Studies have shown, however, that some men with undetectable viral loads still have HIV in their semen, so all were advised that the risk of transmission was not zero.
If both partners are positive, the only risk to the adults is being superinfected with the partner's strain of HIV, which may be resistant to the meds the other partner is taking. If both partners are on HIV treatment and have undetectable viral loads, this risk is dramatically reduced. Both should be checked for STIs beforehand.
But there is still some uncertainty as to the risk of maternal HIV therapy, whether it be for treatment of her own infection or for PrEP, on the newborn, either early on or as that individual ages, and goes through different developmental stages. Some of this vagueness is due to the lack of long-term studies of the effects of HIV medications taken during the earliest stages of pregnancy on the newborn. It is also important to remember that the potential risk of toxicity to the newborn is greatest if exposure occurs during the first trimester of pregnancy. Unfortunately, most of the information concerning these risks is being collected through the Antiretroviral Pregnancy Registry (apregistry.com), which is voluntary and non-comparative.
Lastly, if the woman becomes pregnant and is HIV positive, it is important that she be followed regularly through pregnancy. Adherence is difficult, especially during the first trimester when nausea and vomiting are common and can be severe. Drug levels of many of the therapies are affected by pregnancy and may need to be altered at different times during the pregnancy. Optimal care is best done by a partnership with a knowledgeable clinician.
The bottom line is that having a baby when you have HIV is possible, but only safe when done in consultation with a medical provider who is an expert in this area. Simply taking off the condoms or attempting artificial insemination at home without medical advice is risky and often not effective. Discuss all your options with your care provider, clearly assess the risks, and use the approach that's best for you.
Mark Milano is the Editor of Achieve.