Safer Conception Options for HIV Serodifferent Couples in the United States

To the Editors: Over half of HIV-positive adults in heterosexual partnerships in the United States report having an HIV-negative partner.1 Moreover, the Centers for Disease Control and Prevention estimate approximately half of the 140,000 heterosexual serodifferent couples in the United States desire children.2 The largest population-based study of heterosexual HIV-infected adults in the United States found 29% of HIV-positive women desire future fertility compared with 36% of reproductive-aged women in the general US population. Other studies indicate that 59% of HIV-positive women engaged in care in the United States expressed a desire for children, with this proportion increasing to 80% among HIV-positive young women.3,4 The only published study evaluating the fertility desires of HIV-positive heterosexual men in the United States reported that 28% wanted children.1 Given HIV-affected couples' desires to have children, services focusing on safer conception, supportive of reproductive health decision making, are urgently needed. For HIV-positive female/HIV-negative male serodifferent couples, home insemination using ejaculated semen is a low-cost intervention posing no risk of HIV transmission to the HIV-negative male partner, assuming that the couples consistently use condoms.5–7 However, HIV-positive male/HIV-negative female couples who desire conception contend with the issue of HIV infectivity of semen. There are several safer conception interventions for HIV-positive male/HIV-negative female couples including assisted reproductive technologies (such as intrauterine insemination or in vitro fertilization) with donated or washed sperm, timed intercourse with suppressive antiretroviral therapy for the infected man with or without pre-exposure prophylaxis to the uninfected woman, or adoption.2,8 However, couples and their health care providers may not be aware of the range of options available to reduce the risk of HIV transmission to the uninfected partner during conception attempts. Furthermore, even when couples are informed of the options, they may lack access, because of cost or location, to assisted reproduction technologies, such as sperm washing and in vitro fertilization.9 Little is known about the knowledge gaps and referral needs of clinicians and HIV serodifferent couples regarding conception options. To better understand these needs, we sought to evaluate the types of calls made to the National Perinatal HIV Hotline and Clinicians' Network related to conception for HIV-affected couples. The National Perinatal HIV Hotline and Clinicians' Network is a Health Resources and Services Administration-funded initiative operated by the University of California, San Francisco Department of Family and Community Medicine at the San Francisco General Hospital. The National Perinatal HIV Hotline provides free 24-hour consultation for US clinicians on HIV care from preconception through pregnancy and birth. Additionally, HIV-positive pregnant women and their exposed infants are referred to local experts for care through the Perinatal HIV Clinicians' Network that includes over 300 providers nationwide. Calls to the National Perinatal HIV Hotline are entered in a centralized database including caller demographics and call details. For this analysis, we evaluated all calls to the National Perinatal HIV Hotline and referrals to the Perinatal HIV Clinicians' Network between January 1, 2006, and December 31, 2011. Calls pertaining to conception were identified through key word search. We evaluated trends over time in the number of calls related to conception using the extended Mantel–Haenszel χ2 test for linear trend. We categorized calls by the direction of serodifference in the couple and the types of questions asked. Question types were classified as legal queries, referrals for assisted reproduction, and requests for nonassisted conception options. During the study time period, there were 2183 total calls and 246 total referrals to the National Perinatal HIV Hotline and Clinicians' Network. Of these 2429 calls and referrals, 152 (6.3%) regarded conception for serodifferent couples: 68 (45%) from patients and 84 (55%) from clinicians. Total call volume increased over time with a statistically significant increase in the number of calls related to conception for HIV-affected couples (P value for trend < 0.001, Fig. 1). Most calls (83.6%) were related to HIV-positive male/HIV-negative female couples. Sixty-three percent of the callers specifically requested referrals to fertility clinics offering assisted reproduction. Thirty-four percent sought advice on alternative interventions such as timed intercourse and pre-exposure prophylaxis when assisted reproduction was either unavailable or unaffordable, and 2.6% of the callers inquired about state laws related to assisted reproduction for serodifferent couples.FIGURE 1: Safer conception calls by year.A growing number of HIV serodifferent couples are looking for referrals to providers supportive of their reproductive health choices. HIV-affected couples and their providers increasingly seek advice on safer conception options through the National Perinatal HIV Hotline and Clinicians' Network. Providing safer conception options to HIV serodifferent couples is critical to promoting the reproductive rights of HIV-affected couples in the United States. As both primary care and HIV experts integrate sexual and reproductive health care into their routine practice, HIV serodifferent couples can be made aware of safer conception options and guided to safely realize their family building goals.