eCase - HIV Prevention

Overview of HIV Prevention

Released: September 17, 2020

Expiration: September 16, 2021

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Introduction Behavioral Modifications Male Condoms Female Barrier Devices and Hormonal Contraception Treatment of Sexually Transmitted Diseases and HIV Acquisition Male Circumcision Nonspecific Microbicides Pre-Exposure Prophylaxis Antiretroviral Therapy for Prevention Preventing HIV Transmission to Uninfected Partners in Women Attempting Conception Vaccines for HIV Prevention Building a Combination Approach to HIV Prevention Primary Care Essentials References

There are now multiple options for serodiscordant couples who want to conceive while minimizing the risk of transmitting HIV to their uninfected partner. The CDC states that individuals with HIV who are adherent to ART and with a sustained, undetectable viral load have essentially no risk of transmitting HIV through sex.¹²⁵ The data from HPTN-052¹² showing a greatly reduced risk of HIV transmission from HIV-infected partners with undetectable HIV-1 RNA during ART, combined with the data from the Partners PrEP study⁹ showing reduced risk of HIV acquisition in individuals taking daily oral emtricitabine/tenofovir DF, have increased the options for HIV serodiscordant couples planning a pregnancy. It is important to note that genetically linked HIV transmissions did not occur while the partner with HIV was virologically suppressed. If ART is initiated in the partner with HIV, the DHHS guidelines panel recommends that maximal virologic suppression is attained before attempting conception.¹²⁶ Administering oral PrEP to the partner without HIV is recommended if viral suppression in the partner with HIV has not been achieved or if their viral suppression status is unknown. Data from a modeling study that examined the usefulness of PrEP when condomless sex acts occurred only during the ovulation period or when sex acts were not limited to ovulation, showed that PrEP provided little added benefit when the male partner was on ART and had a suppressed viral load and when the couple limited sex without a condom to the ovulation period and improved other modifiable transmission risks.¹²⁷ The panel recommends that education about the potential risks and benefits and all available alternatives for safer conception be provided when prescribing PrEP to serodiscordant couples. CDC guidelines recommend that a woman without HIV who is planning a pregnancy with a partner who has HIV infection start daily oral emtricitabine/tenofovir DF 1 month before trying to conceive and continuing for 1 month after conception occurs.⁷³If the couple is going to continue having condomless sex after conception and the partner with HIV has not achieved sustained viral suppression, the partner without HIV should continue to take PrEP to decrease the risk of secondary transmission.

The DHHS recommendations for serodiscordant couples who want to conceive include the following ART interventions¹²⁶:

Partners with HIV should attain sustained viral suppression (eg, 2 plasma HIV-1 RNA measurements below the limits of detection and at least 3 months apart) before trying to conceive to optimize their health, block HIV sexual transmission and, for pregnant women with HIV, to reduce the risk of HIV transmission to the infant.

For serodiscordant couples where the partner with HIV is receiving ART with sustained viral suppression, sexual intercourse without a condom allows for conception with effectively no risk of sexual HIV transmission to the partner without HIV.

Providers should counsel patients about the option of the partner without HIV taking PrEP when the partner with HIV has achieved viral suppression.

Other, non-ARV interventions are also available. The DHHS recommendations include the following¹²⁶:

Expert consultation is recommended for serodiscordant couples desiring to conceive so that approaches can be tailored to the specific needs of each couple.

Partners should be screened and treated for genital tract infections before attempting to conceive.

For women with HIV who have male partners without HIV, artificial insemination, including the option of self-insemination with a partner’s sperm during the periovulatory period, eliminates the risk of HIV transmission to the uninfected partner.

For men with HIV who have female partners without HIV, artificial insemination with donor sperm from a male without HIV eliminates the risk of HIV transmission to the uninfected partner. In addition, it is recommended that males with HIV undergo semen analysis before attempting conception to prevent unnecessary HIV exposure if the likelihood of conception is low because of semen abnormalities.

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