As primary care providers for a significant proportion of women in their practices, ob/gyns need to be holistic in their approach to patient care. This includes a comprehensive assessment of risk factors for different diseases, including HIV. This article underscores the importance of keeping up to date on the latest evidence and recommendations on HIV prevention. The focus is on the Undetectable=Untransmittable (U=U) advocacy campaign, which has been essential in disseminating key science to both the healthcare community and the general public.

Ob/gyns must provide the highest quality, most effective care for patients who may be at risk for acquiring HIV, and for women living with HIV (WLHIV). Prevention has always been a cornerstone of high-quality and cost-effective medical care, but the growing understanding of how to effectively prevent HIV transmission makes this even more imperative. Ob/gyns also must consider how best to help women achieve their reproductive heath goals while preventing HIV acquisition or transmission to their partner.

Current guidelines and HIV prevention
The most recent American College of Obstetricians and Gynecologists (ACOG) guidelines to address gynecologic care for WLHIV are Practice Bulletin (PB) 167 and Committee Opinion 595.1,2 PB 167 includes treatment considerations and recommendations for prevention of transmission to uninfected partners,1 while the Committee Opinion specifically describes use of pre-exposure prophylaxis, or PrEP, for women at high risk of exposure to HIV. Screening and recommendations for prevention of mother-to-child transmission of HIV are detailed in other PBs and clinical guidelines, and are not the focus on this article.2,3 PB 167 integrates the 2016 Department of Health and Human Services (DHHS) recommendation that antiretroviral therapy with a triple drug regimen be initiated in all adults and adolescents diagnosed with HIV, regardless of their current clinical symptoms or CD4+ count.1, 3 This update replaced previous recommendations for therapy based on a threshold CD4+ count, pregnancy or clinical signs of immunosuppression. In addition, the DHHS guidelines suggest that male partners of WLHIV may take a daily antiretroviral pill (tenofovir/emtricitabine or PrEP) to reduce risk of HIV acquisition.

Consistent use of antiretroviral therapy reduces risk of short and long-term complications of HIV, including risks related to immunosuppression and development of drug resistance. Use of effective antiretroviral therapy that induces HIV viral suppression, which is the reduction of HIV viral load in the blood to undetectable levels, is a powerful HIV prevention mechanism, also known as Treatment as Prevention (TasP). In addition to several smaller studies, three large, randomized studies that
included over 3300 couples in which the infected partner was virally suppressed on anti-retroviral therapy for at least 6 months showed no HIV transmissions to the HIV-negative partner.4-8 That protection has been shown to be durable for over 10 years in Switzerland, which has seen an overall decrease in HIV incidence despite an increase in condomless sex over the past decade, and reports no documented HIV transmission in the setting of suppression.9 Since these studies were published, researchers, advocates and patients have sought clarity on the practical implications for serodiscordant couples. What about condoms? PrEP? A combination of TasP + PrEP? These nuanced questions are especially relevant for serodiscordant couples seeking pregnancy, who for a long time have been treated as a high-risk group, and still have recommendations that fall outside of this list of evidence-based options.

Author: Megan J. Huchko, MD, MPH

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