Achieving safe conception in HIV-discordant couples: The potential role of oral preexposure prophylaxis (PrEP) in the United States

Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
American journal of obstetrics and gynecology (Impact Factor: 4.7). 03/2011; 204(6):488.e1-8. DOI: 10.1016/j.ajog.2011.02.026
Source: PubMed


Approximately half of HIV-discordant heterosexual couples in the United States want children. Oral antiretroviral preexposure prophylaxis, if effective in reducing heterosexual HIV transmission, might be an option for discordant couples wanting to conceive. Couples should receive services to ensure they enter pregnancy in optimal health and receive education about all conception methods that reduce the risk of HIV transmission. In considering whether preexposure prophylaxis is indicated, the question is whether it contributes to lowering risk in couples who have decided to conceive despite known risks. If preexposure prophylaxis is used, precautions similar to those in the current heterosexual preexposure prophylaxis trials would be recommended, and the unknown risks of preexposure prophylaxis used during conception and early fetal development should be considered. Anecdotal reports suggest that oral preexposure prophylaxis use is already occurring. It is time to have open discussions of when and how preexposure prophylaxis might be indicated for HIV-discordant couples attempting conception.

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    • "Although recent data are not available, a study of a population-based sample of HIV-infected persons in care in 1996 found that 58% of men and 70% of women had a primary partner or spouse; approximately 50% of couples were in serodiscordant relationships and almost 20% were in relationships with partners whose HIV status was unknown [13]. Extrapolating from this information and incorporating 2006 data about number and demographics of heterosexual adults living with HIV in the U.S., it has been estimated there are approximately 140,000 HIV-heterosexual serodiscordant couples in the US, about half of whom want more children [28]. This has significant implications about the need to provide accurate information about achieving safe conception in the presence of HIV discordance. "
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    ABSTRACT: Women living with HIV have fertility desires and intentions that are similar to those of uninfected women, and with advances in treatment most women can realistically plan to have and raise children to adulthood. Although HIV may have adverse effects on fertility, recent studies suggest that antiretroviral therapy may increase or restore fertility. Data indicate the increasing numbers of women living with HIV who are becoming pregnant, and that many pregnancies are unintended and contraception is underutilized, reflecting an unmet need for preconception care (PCC). In addition to the PCC appropriate for all women of reproductive age, women living with HIV require comprehensive, specialized care that addresses their unique needs. The goals of PCC for women living with HIV are to prevent unintended pregnancy, optimize maternal health prior to pregnancy, improve maternal and fetal outcomes in pregnancy, prevent perinatal HIV transmission, and prevent HIV transmission to an HIV-uninfected sexual partner when trying to conceive. This paper discusses the rationale for preconception counseling and care in the setting of HIV and reviews current literature relevant to the content and considerations in providing PCC for women living with HIV, with a primary focus on well-resourced settings.
    Infectious Diseases in Obstetrics and Gynecology 10/2012; 2012:604183. DOI:10.1155/2012/604183
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    • "Current HIV prevention strategies (condoms and abstinence ) force HIV-serodiscordant couples to choose between risking HIV transmission to a partner, or accepting childlessness [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]. Behavioral strategies (home artificial insemination , sex without condoms limited to peak fertility), male circumcision [13] [14] [15], antiretroviral therapy (ART) for the infected partner [16] [17] [18], and preexposure antiretroviral prophylaxis (PrEP) for the negative partner [19] [20] [21] [22] create opportunities for HIV-serodiscordant couples to realize fertility goals and minimize periconception HIV transmission [23] [24] [25] [26] [27]. Prior to effective HIV treatment, the prevailing professional recommendation was for people living with HIV to avoid having children [28] [29]. "
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    ABSTRACT: Understanding HIV-infected patient experiences and perceptions of reproductive counseling in the health care context is critical to inform design of effective pharmaco-behavioral interventions that minimize periconception HIV risk and support HIV-affected couples to realize their fertility goals. We conducted semistructured, in-depth interviews with 30 HIV-infected women (with pregnancy in prior year) and 20 HIV-infected men, all reporting serodiscordant partners and accessing care in Durban, South Africa. We investigated patient-reported experiences with safer conception counseling from health care workers (HCWs). Interview transcripts were reviewed and coded using content analysis for conceptual categories and emergent themes. The study findings indicate that HIV-infected patients recognize HCWs as a resource for periconception-related information and are receptive to speaking to a HCW prior to becoming pregnant, but seldom seek or receive conception advice in the clinic setting. HIV nondisclosure and unplanned pregnancy are important intervening factors. When advice is shared, patients reported receiving a range of information. Male participants showed particular interest in accessing safer conception information. HIV-infected men and women with serodiscordant partners are receptive to the idea of safer conception counseling. HCWs need to be supported to routinely initiate accurate safer conception counseling with HIV-infected patients of reproductive age.
    Infectious Diseases in Obstetrics and Gynecology 08/2012; 2012(4):146348. DOI:10.1155/2012/146348
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    • "HIV transmission within stable serodiscordant partnerships is thought to contribute substantially to the HIV epidemic in sub-Saharan Africa [2]. In the United States, it is estimated that there are more than 140,000 HIV serodiscordant heterosexual couples [3]. In HIV serodiscordant partnerships where conception occurs, the HIV-uninfected partner has a 1.8 (95% confidence interval (CI) 1.01–3.26; "
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    ABSTRACT: HIV serodiscordant couples represent at least half of all HIV-affected couples worldwide. Many of these couples have childbearing desires. Safer methods of conception may allow for pregnancy while minimizing the risk of sexual transmission of HIV. In serodiscordant partnerships with an HIV-infected female and HIV-uninfected male, vaginal insemination of a partner's semen during the fertile period coupled with 100% condom use may be the safest method of conception.
    Infectious Diseases in Obstetrics and Gynecology 08/2012; 2012(3):587651. DOI:10.1155/2012/587651
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