Pinned to the bulletin board over my desk is a birth announcement with stunning photos and the quote, "I prayed for this child and the Lord has granted me what I asked of him - 1 Samuel 1:27." Next to it is a card with a photo of a couple embracing and the words, "Thank you for believing in us." Then a black and white photograph my teen daughter took at a first birthday party, chubby baby arms grabbing at the birthday cake on the highchair tray. These mementos give me goose bumps. Witnessing someone's dream come true is a gift. I once joined a couple and their baby. As the parents ate their salad amongst the bustle of San Francisco's financial district lunch crowd and took turns holding the baby, I looked around wishing everyone could perceive this great love. I wondered what it is like to be this child -- to grow up having been so wanted, so planned for, so desired.
While condoms have been the gold-standard HIV prevention method, when HIV-affected couples want to have a baby, they must necessarily consider other options, weighing the risk of possible HIV transmission with their natural desires to have a child. Assisted reproductive technologies, such as sperm washing combined with intrauterine insemination or in vitro-fertilization, have been offered to HIV-affected couples through some fertility clinics, but many couples are unable to access these services due to cost or location.
Assisted reproductive technologies are not always necessary. Data from recent clinical trials now offer additional options to reduce sexual HIV transmission, expanding the safer conception methods available for HIV-affected couples.
First, HIV-positive individuals who take antiretroviral medications and have their virus fully suppressed reduce their risk of transmitting HIV to a partner by 96%, a strategy known as treatment as prevention. Second, data from pre-exposure prophylaxis (PrEP) trials demonstrate HIV-negative individuals adherent to taking antiretroviral medication dramatically reduce their risk of acquiring HIV. In fact, there were zero HIV transmissions to PrEP research participants who took four or more doses per week. Based on these data, timed intercourse with or without PrEP provides effective, lower cost choices for HIV-positive male/HIV-negative female couples to conceive. When engaged in care with a knowledgeable provider, HIV-affected couples can plan for a pregnancy where the woman, and thereby the infant, remains HIV-negative.
Even with this tremendous news, HIV-affected couples experience stigma related to their fertility desires from friends, family and medical providers. Many HIV-positive men in our Bay Area Perinatal AIDS Center's PRO Men (Positive Reproductive Outcomes for HIV-positive Men) initiative, based at San Francisco General Hospital and Trauma Center's Ward 86 HIV Clinic, report a desire to have a child. But they also say they've never been asked by their providers whether they want to have a child. In nearly every support group, one theme emerges: I just wish people understood. I wish people knew I can be like Magic Johnson. I wish people knew about an undectable viral load and the possibilities for having a family.
The truth is the story has changed from one of risk reduction and permission giving to one of possibility and hope. It's time our collective knowledge and attitudes caught up with the science. We've arrived at new point in the HIV epidemic -- a compelling opportunity to harness the available behavioral and biomedical interventions toward the elimination of sexual HIV transmission. HIV-affected couples can have healthy sex lives and families.
The photos of the families on the bulletin board above my desk are living proof.
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