Conception Options for HIV Serodiscordant Couples

With more than 30 million people infected with HIV worldwide and the relatively recent advent of highly active antiretroviral therapies (HAART) resulting in much longer life expectancy for infected HIV patients, couples with either one or both partners infected by HIV (respectively termed serodiscordant or seroconcordant) have expressed increased interest in childbearing. Though many of these patients utilize assisted reproductive techniques, more than one paper has recently advocated for HIV serodiscordant couples to engage in unprotected sexual intercourse during fertile days when treated by HAART with a consistently undetectable serum viral load, particularly when adherence is excellent and no STDs are present. These points of view have been criticized by others, the argument being that abandonment of condom use in these couples can potentially quadruple the number of contaminations and negatively impact public health. The article under review analyzes current data in an attempt to summarize the risks associated with unprotected sexual intercourse targeting fertile days in HIV serodiscordant couples.

Most data suggests that although the absolute cumulative annual risk of transmission of HIV to the seronegative partners is very low, –on the order of 2 to 4 per 1000 in a couple participating in 100 acts of sexual intercourse per year—the rate of transmission is higher when the male partner is already HIV infected and the woman is seronegative (i.e. has a negative test for HIV). Numerous studies exist which demonstrate that patients treated with HAART who have undetectable serum viral loads have decreased transmission risks to an unaffected partner. Similar studies have documented that the existence of sexual transmitted diseases such as herpes simplex and bacterial vaginosis increase the risk of transmission to a healthy partner. Unfortunately, HIV in the genital reservoir—be it spermatic or vaginal-- does not always correspond to the value of viral concentrations and genotypes in the bloodstream. One study showed that one-third of women and four percent of men with undetectable viral loads have detectable viral RNA in their genital secretions, suggesting that using the serum viral load as a surrogate for genital viral load is not advisable. Another caveat is that the reported rates of seroconversion (“becoming HIV positive”) come from stable discordant couples having unprotected sexual intercourse, and their rate is approximately ten times lower than those for non-stable couples engaging in “occasional” sexual contacts. It is unclear whether the couples’ serodiscordance is a result of natural selection—meaning the unaffected partner is somehow genetically protected—or whether the apparent immunity is something that may have been acquired. Some authors believe that serodiscordant couples who are using condoms and decide to have unprotected intercourse in order to conceive have a risk more akin to “occasional” sexual contacts.

The number of acts of sexual intercourse necessary to conceive, as well as the risk of maternal transmission to the fetus, also bears weighty consideration. The average number of sexual acts during the fertile days of the woman’s cycle necessary to achieve pregnancy for a normal fertile couple is between 3 and 10. Applying this data to serodiscordant couples would mean that the risk of HIV seroconversion would be one per thousand pregnancies. However, several studies suggest that HIV carriers on HAART have reduced fertility, meaning more unprotected sexual acts would be necessary in order to conceive, resulting in a higher risk of HIV seroconversion per pregnancy. In HIV serodiscordant couples in which the infected partner is a man, the seroconversion of the future mother and high viral loads following unprotected intercourse at the time of conception lead to a higher risk of the fetus being infected with HIV.

Data revealing that 45 percent of heterosexual, stable HIV serodiscordant couples have had unprotected sex within the past 6 months suggests that recommendations focusing on condom use to prevent HIV are already being ignored. Proponents of temporary consent for unprotected intercourse in these couples argue that by doing so, patient reliance on assisted reproductive technologies (ART) is reduced. This is not a trivial concern, especially since it has been reported that up to half of HIV-infected serodiscordant couples have not encountered success with ART. However, for couples with a female HIV-infected partner, auto-insemination is a safe and autonomous means of conceiving. And in women who become pregnant, ongoing unprotected intercourse carries approximately double the risk of HIV seroconversion due to changes in the maternal defense system. For health professionals to universally advocate that selective abandonment of condom usage is a recommended option for couples interested in conceiving may not only encourage further disregard for prevention policies, but will almost certainly ultimately result in more lives being negatively impacted by HIV.

This article does an exemplary job of presenting the many different concerns of which patients and providers must be aware when caring for serodiscordant couples who are interested in conceiving. Though ultimately patients must make their own decisions with respect to what level of risk is acceptable for them, the authors accurately portray that the risk of HIV seroconversion for serodiscordant couples considering engaging in unprotected sexual intercourse is not zero, and may have far-reaching effects if routinely encouraged.

--Summarized by Barrett Robinson, MD, MPH