A report issued by researchers at the Centers for Disease Control and Prevention (CDC) and Emory University School of Medicine states that condomless intercourse can take place between an HIV-negative woman and her HIV-positive partner if the couple employs certain preventive measures.
One strategy is for the man to achieve viral suppression using highly active antiretroviral therapy (HAART) while his female partner takes the daily oral antiretroviral preexposure prophylaxis, known as PrEP. The couple, while using these interventions, may also go a step further by having the man’s sperm collected and “washed” to get rid of HIV-infected cells. This procedure is followed up by sperm testing to ensure that the sample is free of HIV; studies show that 92% to 99% of washed sperm do not have any detectable levels of virus. At this point, the sperm are inserted directly into the uterus through intrauterine insemination (IUI) or used to fertilize the woman’s eggs in an in vitro fertilization (IUI) procedure.
For HIV-discordant couples in which there are no known fertility problems, the HAART/PrEP method alone may be sufficient to having transmission-free conception. However, HIV can cause semen changes in men that may make conception via intercourse difficult. In these cases, IUI may be the best option. Similarly, if a woman’s fertility is impaired in any way, assisted reproductive technologies can help. Because of this, any HIV-discordant couple hoping to conceive should undergo a full fertility workup that can help practitioners determine the best course of action.
While condomless intercourse has traditionally been a significant risk factor in HIV infection, studies have shown that when a man’s blood and semen viral load are adequately suppressed on HAART, the risk of transmission is 0.16 per 10,000 exposures. The question remains, however, whether it’s enough to simply test a man’s blood viral levels before giving the go-ahead to condomless intercourse. According to the report, while some studies indicate that a blood viral level is correlated with the viral level in semen, other studies demonstrate that men with undetectable blood viral levels may still shed a bit of the virus in their semen. The rate of transmission remains low in this case, but it may not be low enough for comfort. To ensure the absolute lowest risk of transmission, a woman will want to use PrEP and limit condomless intercourse only to the time of ovulation.
Ultimately, each couple will have to decide how much physical risk they’re comfortable taking along with how much financial risk, as assisted reproductive technology can be pricey and success is not guaranteed. It’s also worth remembering that even after a successful, infection-free conception and pregnancy, a woman may still become infected by her partner if the two engage in condomless intercourse at any point.