Planning a Pregnancy

• Planning Your Pregnancy
• The Swiss Statement

Planning Your Pregnancy

Preconception, planned pregnancy, and your rights to have a baby

Many HIV-positive women become pregnant when they already know their HIV status. Many women are also already taking anti-HIV drugs 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:

• consider your general health;
• have appropriate check ups; and
• treat any sexually transmitted infections.

You should also make sure you are receiving appropriate care and treatment for your HIV.

It is reassuring to know that over 1000 HIV-positive pregnant women had uninfected babies in the UK in 2006.

• Choose a healthcare team and maternity hospital that supports and respects your decision to have a baby.
• If you are not supported in this decision, then you should arrange to see a doctor and healthcare team with more experience in dealing with HIV.
• You may not be able to travel to a centre with this expertise. In this case, you should contact them for advice, support and to find out your rights.

What to do when one partner is HIV-positive and the other is HIV-negative

There is still controversy over the best advice to give to sero-different (the medical term is sero-discordant) couples. (These are terms for when one partner is HIV-positive and the other HIV-negative.)

It is usually unwise for sero-different couples to have unsafe sex. Even when politely called a "conception attempt", there is always a risk to the HIV-negative partner of contracting HIV.

For an HIV-negative woman, for example, the chance of becoming HIV-positive from having unprotected sex will depend on many things, including the viral load in the semen of her male partner. It is important to remember that an undetectable viral load result from a blood test does not mean that viral load is undetectable in seminal fluid.

For an HIV-negative man, transmission risk depends on the level of viral load in the genital fluids of his female partner. Again, an undetectable viral load in blood does not always mean the same as in genital fluid.

Other factors are also important. An uncircumcised man is likely to be more at risk of contracting HIV because cells in the foreskin are more vulnerable to infection. And having sex with an uncircumcised HIV-positive man is of greater risk to an HIV-negative woman than sex with a circumcised man.

Infections of the genital tract also increase the risk of sexual transmission of HIV. Regardless of the method of conception, both members of a sero-different couple should check for such infections. This should include screening and treatment for other sexually transmitted infections. The man should have a semen analysis. This can rule out any infection and also to ensure that his sperm count is fit and healthy.

All these risk factors aside, HIV is actually quite a difficult virus to transmit. Statistically it is much harder to transmit HIV than to get pregnant. Therefore, limited conception attempts made during ovulation (a woman's fertile period) may carry a low risk if the positive partner has undetectable levels of viral load (we talk about this and how to make it safest below). But there is still a risk involved for both male and female negative partners from any single unprotected exposure. After all, people can conceive from one attempt and also become HIV-positive from one exposure.

In one study of HIV-negative women and HIV-positive men, 4% of women became HIV-positive. But this study took place before the routine use of HAART.

A more recent study in Spain of 40 sero-different couples conceiving when the man was on HAART and had a viral load of less than 50copies/mL for at least 6 months, had no transmissions.

One additional point should be stressed. Although a low number of conception attempts can be relatively safe, some couples do not return to safer sex afterwards. This sometimes results in the negative partner then becoming HIV-positive.

HIV is still a disease that can affect the rest of your life. If one of you has stayed HIV-negative until now, you don't want to change this over a decision to have a baby.

For those who wish to conceive, the options are discussed on the next pages.

When the man is HIV-positive and the woman HIV-negative

When the man is HIV-positive and the woman is HIV-negative, 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-infected white blood cells; 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.

This is therefore the safest way for an HIV-negative woman to become pregnant from an HIV-positive man.

The disadvantages of sperm washing are cost, access and lower rate of conception.

Very few clinics offer this service in the UK but the clinic with the most experience is the Chelsea and Westminster Hospital in London.

Unfortunately, it is not always possible to obtain this procedure on the NHS, but recently, in some cases people were funded as part of a risk reduction intervention at this clinic.

HIV-prevention or risk reduction funds rather than fertility treatment budgets may therefore be easier to access for sperm washing. Some cycles at Chelsea and Westminster have received NHS funding on a risk reduction basis following a letter of recommendation by the GU doctor to the couple's health authority.

Cost can be a barrier for many to these services and health authorities must address this issue. The Chelsea and Westminster assisted conception unit can be contacted on 0208 746 8585.

As we said earlier, a more controversial option is to have limited conception attempts during the most fertile days in a woman's cycle. To make this safer an HIV-positive man must use HIV treatment to reduce his viral load to undetectable both in blood and semen for at least 6 months. Conception can either be naturally (having gentle sex) or with self insemination. Most doctors can provide guidance on how to plan and identify which days would be appropriate.

Viral load in semen can be tested using the same viral load tests that are used for blood, and your clinic could advise on this.

Approximately 10% of people with undetectable levels in blood, can have detectable levels in semen, so this could offer additional safety.

Artificial or self-insemination (see below) would reduce the risk of trauma during sex where a small tear could increase the risk of HIV transmission.

Continuing to use condoms at all other times is essential.

This is more controversial because there is still a small risk of transmitting HIV. However, especially where sperm-washing is not available, there have been encouraging reports (like the Spanish study of 60 couples) that this has been successful. For many women who want to have children, this risk may be acceptable, but it must be something that she decides to do herself and is not pressurised into.

If you do decide to do this, there may be an additional safety benefit from the woman using 1-2 days of HIV-drugs to reduce the slight chance of infection even further. Several studies are looking at whether using tenofovir and FTC (or 3TC) before exposure to HIV can be protective.

When the woman is HIV-positive and the man is HIV-negative

The options are usually much simpler in this situation. Do-it-yourself artificial insemination or "self insemination" using a plastic syringe carries no risk to the man. This is the safest 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 protected 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.

When both partners are HIV-positive

For couples in which both partners are HIV-positive, most doctors still recommend safer sex. This is to limit the possibility of re-infection with a different strain of HIV. However reinfection is only a risk if one partner has drug resistance or a different type of HIV.

It is likely that the risk is low, but it is possible. Re-infection is even less likely if you only have unprotected sex a few times in order to conceive a baby. Here are some other things to consider about the risk of reinfection:

• The risk will relate to viral load levels and be very low if you are on treatment.
• This consequence is only likely to be important if one partner has drug resistance, especailly if they also have a high viral load.

If you routinely practice safer sex, you may want to limit unprotected sex to the fertile period. You could also follow the advice for serodifferent couples.

For HIV-positive couples who do not practice safer sex now, continuing to do so to conceive a baby will carry no additional risk.

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 it 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 just as 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. If you do, then you can and should complain about this.

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

The Swiss Statement The "Swiss Statement" was issued in January 2008 by the Swiss Federal Commission on AIDS Related Issues (an expert group of doctors and researchers). This group was concerned about the legal situation to HIV-positive people in Switzerland and for serodifferent couples who wanted to have a baby. They were worried about the accuracy of public and private information about the risk of HIV transmission for people on antiretroviral treatment. One of the reasons that they issued the statement was to give doctors guidance to help serodiscordant couples wishing to conceive a child. Many couples are unable or unwilling to use sperm washing or other methods of assisted reproduction and need to be able to make informed decisions about the level of risk involved with having sex when using antiretrovirals. The statement described the transmission risk for someone on stable therapy as "negligible" and "similar to risks of daily life" It explains that, for example, even condom use is not 100% safe. The statement makes it very clear that this description of someone at a very low risk of transmission only applies to someone who: Has an undetectable viral load for at least 6 months Has excellent adherence Has no other STIs. The Swiss doctors calculated that conceiving naturally under these cirumstances would be unlikely to lead to HIV infection in the HIV-negative partner. They were not recomending that condoms should now be abandoned forever -- just that the risks during limited conception attempts were so small compared to the importance for many couples to have children. They also stated that PEP treatment wouldn't be given if a condom broke and the HIV-positive partner fullfilled the above criteria. If you want to read more about The Swiss Statement: www.aids.ch/e/fragen/pdf/swissguidelinesART.pdf