According to the United Nations Joint Programme on HIV/AIDS, nearly half of all HIV-affected couples in the world are serodiscordant, meaning that one partner is HIV-positive while the other is HIV-negative. Today, in the U.S. alone, it is estimated that there are over 140,000 serodiscordant heterosexual couples, a great many of whom are of child-bearing age.

With major advances in antiretroviral therapy (ART), as well as other preventative interventions, serodiscordant couples have far greater opportunities to conceive than ever before—allowing for pregnancy while minimizing the risk of transmission to both the child and uninfected partner.

Preconception Considerations

Today, it is widely accepted that the proper use of antiretroviral drugs can dramatically reduce the risk of infection among HIV serodiscordant partners by:

ensuring that the HIV-positive partner has reduced infectivity by maintaining the viral load at undetectable levels (a strategy known as treatment as prevention, or TasP)

providing the HIV-negative partner with the option for added protection with the use of pre-exposure prophylaxis (PrEP)

In couples using both TasP and PrEP, the risk of transmission is seen to be significantly decreased. Research from the ongoing PARTNERS study showed that of 1,166 couples enrolled in a trial from September 2010 to May 2014, only 11 HIV-negative partners were infected. However, genetic testing also revealed that all eleven were infected by someone outside of the relationship, meaning that no one in a presumably monogamous relationship was infected.

However, it’s important to note that while these interventions can greatly minimize risk—by up to 96 percent and 74 percent, respectively— they don’t eliminate them entirely. A number of other factors, including HIV drug adherence and genital tract infections, can take back many of the gains afforded by TasP or PrEP if not properly addressed and treated.

Recent studies have also shown that a person with an undetectable plasma viral load may not necessarily have an undetectable genital viral load. So, while a blood test may suggest a low risk of infectivity, there may be the continued risk on an individual level. It is important, therefore, to seek preconception counseling by a qualified specialist before embarking upon any course of action. Pills alone are not the solution.

If the Female Partner Is HIV-Positive

In a relationship where the woman is positive and the man is negative, the safest option is inter-uterine insemination (also known as artificial insemination, or IUI). It eliminates the need for sexual intercourse and allows for self-insemination using the partner’s sperm.

However, this may not be a viable option for some, either because of cost or other factors. It is, therefore, not unreasonable to explore conception by means of unprotected sex given that measures are in place to minimize transmission risk.

In such cases, the woman would be placed on appropriate ART if it has not yet been prescribed, with the aim of achieving a sustained undetectable viral load. Not only does this decrease the potential for female-to-male transmission, it reduces the risk of mother-to-child infection as well.

Once maximal viral suppression has been achieved, timed unprotected intercourse using ovulation detection methods can further reduce risk. Condoms should be used at all other times. The use of PrEP in the male partner may also provide additional protection, although results are still pending from studies investigating the use of PrEP in pregnancy.

Before initiating PrEP, the male partner should be screened for HIV, hepatitis B, and other sexually transmitted diseases, as well as be given a baseline analysis of kidney enzymes. Regular monitoring should be performed to avoid treatment side effects, including renal dysfunction and other potential toxicities. Additionally, both the female and male partner should be screened for genital tract infections. If an infection is found, it should be treated and resolved before any conception attempt is made.

Once a pregnancy has been confirmed, ART would be continued in the female partner, with current guidelines recommending permanent, life-long therapy irrespective of the CD4 count. All other provisions for the prevention of mother-to-child transmission would then be implemented, including the option for a scheduled cesarean section and the administration of post-natal prophylactic medications for the newborn.

If the Male Partner Is HIV-Positive

In a relationship where the man is positive and the woman is negative, sperm washing coupled with either IUI or in vitro fertilization (IVF) may provide the safest means of conception. Sperm washing is accomplished by separating the sperm from the infected seminal fluid, the former of which is then placed in the uterus after determining the time of ovulation.

If neither IUI nor IVF is an option—with an IUI costing $895 and an IVF costing $12,000, on average—then considerations should be made to explore safer, "natural" methods of conception.

It is highly recommended that a semen analysis be performed at the onset. A number of studies have suggested that HIV (and possibly antiretroviral therapy) may be associated with a higher prevalence of sperm abnormalities, including low sperm count and low motility. If such abnormalities are left undiagnosed, the female may be placed at unnecessary risk with little or no real chance of getting pregnant.

Once fertility viability is confirmed, the first and foremost concern would be to place the male partner on ART with the aim of achieving a sustained, undetectable viral load. The female partner can then explore the use of PrEP to further minimize risk, with similar recommendations for pre-treatment screenings and follow-up.

Unprotected intercourse should be accurately timed to ovulation, using standard detection methods and/or ovulation predictor kits like the Clearblue Easy or First Response urine tests. Condoms should be used at all other times.

Once a pregnancy has been confirmed, the female partner should be screened for HIV as part of the routine panel of perinatal tests. She should also be advised about continued condom use as well as the symptoms of acute retrovirus syndrome (ARS) to help better identify a possible HIV infection.

It is further recommended that a second HIV test be performed during the third trimester of pregnancy, preferably before 36 weeks, or that a rapid HIV test be given at the time of delivery for those who have not tested during the third trimester. In the event that an HIV infection has occurred, appropriate measures should be given to reduce the risk of perinatal transmission, including the initiation of appropriate antiretroviral prophylaxis and the consideration of elective cesarean section.