Achieving Pregnancy Safely in HIV-Affected Individuals and Couples: An Important Strategy to Eliminate HIV Transmission From Mother-To-Child and Between Sexual Partners
HIV-infected individuals are living longer, more productive lives. HIV-affected individuals and couples experience personal and social desires to reproduce for all the same reasons as uninfected individuals and couples,1 and thus require safe reproductive options. HIV prevention interventions often do not consider the childbearing desires of HIV-affected individuals or couples, especially in low- and middle-income countries (LMICs). Failure to assist women with desired fertility can contribute to continued HIV transmission and must be addressed within national elimination of mother-to-child transmission (eMTCT) strategies. A human rights perspective suggests that HIV-affected couples* should have the same ability to choose if and when to have children as HIV-unaffected couples, including access to pre-pregnancy counseling, contraceptives, and, when needed, abortion services. This holistic view includes assistance in mitigating HIV transmission risk when children are desired. In high-income countries, HIV-affected individuals and couples have access to an array of options: (1) treatment of the HIV-infected partner as prevention of transmission to the uninfected partner in conjunction with timed condomless intercourse2**; (2) preexposure prophylaxis (PrEP) for the uninfected partner3; (3) assisted reproductive services, including timed vaginal insemination and sperm washing with intrauterine insemination or in-vitro fertilization4,5 4,5; (4) sperm donation; and (5) adoption.1,6 1,6 In contrast, access to methods of becoming pregnant in LMICs are limited by cost, availability, and sometimes a lack of appreciation by policymakers of the desires and rights of HIV-affected individuals/couples to have children safely. Simple fertility methods may not be discussed as a component of routine HIV care and treatment counseling due to a lack of awareness or knowledge about their safety, affordability, or efficacy.7 To enhance the armamentarium of HIV prevention and reproductive services to achieve zero perinatal and sexual transmission, “safer conception”, and fertility services should be integrated into existing PMTCT strategies. The existing four-pronged prevention of mother-to-child transmission (PMTCT) strategy, developed by the World Health Organization (WHO), includes (1) prevention of HIV in women of reproductive age; (2) prevention of unintended pregnancy in women with HIV; (3) prevention of HIV transmission from mother to child; and (4) the provision of ongoing care and support to mothers, their children, and their families.8 All four prongs are rooted in prevention of sexual and perinatal HIV transmission, HIV testing, use of ART for mothers and infants, exclusive breastfeeding, and access to contraceptive services. The continuum of care services are included within the third WHO prong, including antenatal, intrapartum, and postpartum/postnatal health care services (Fig. 1). However, provision of education and clinical services for achieving pregnancy safely is not uniquely addressed in the current WHO eMTCT strategy,8 and we believe that they should be included within the continuum of care services of the third prong of the strategy that addresses: “prevention of HIV transmission from mother to child.
