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HIV fertility: new guidelines for HIV pregnancy planning in Canada

July 6, 2012

By Sarah Folk

It was a step toward equality for those living with HIV in Canada as the Canadian National HIV Pregnancy Planning Guidelines were released in June. These guidelines will provide health-care professionals with clinical information and recommendations for assistance with fertility and pregnancy planning decisions for individuals and couples living with HIV.

Based on the World Health Organization premise that, “all couples and individuals have the right to decide freely and responsibly the number and spacing of their children and to have access to information, education and the means to do so,” these guidelines will allow more HIV-positive individuals and couples in Canada to assess fertility options and safely plan their pregnancies.

Shari Margolese, co-author of the guidelines and HIV community research consultant at Women’s College Hospital, explains the significance of the recommendations and the pregnancy planning options available for individuals and couples living with HIV.  

“These are the first stand-alone preconception guidelines that consider same-sex couples and individuals who are looking to start families,” says Margolese. The objective of the program is to link health-care professionals together in order to establish more thorough health and reproductive care in the context of HIV infection.

Studies have shown that the rate of HIV in women is steadily on the rise, and over 70 per cent of Canadian women and men living with HIV are of reproductive age. Furthermore, recent studies have indicated that within seven years of their diagnosis, HIV-positive individuals have the same life expectancy as the general population. Margolese explains that as a result, many HIV-positive men and women are having and will continue to have children, and health-care professionals must be prepared to guide them through this process.

In a 2009 study performed by Dr. Mona Loutfy, co-author of the guidelines and Infectious Disease Specialist at Women’s College Research Institute, it was found that of the 490 HIV-positive Ontario women ages 18-52 included in the survey, 69 per cent desired to give birth and 57 per cent intended to give birth in the future. This indicates a strong need for preconception services for people living with HIV.

“Historically, there were not a lot of fertility options available for HIV-positive women or partners of HIV-positive men,” explains Margolese. “Many clinics would see them and not want to help them.” In fact, the biggest issue surrounding infertility in HIV-positive women is age. “When they were first diagnosed, it was considered unacceptable for them to get pregnant,” says Margolese.

Thus far, HIV reproductive health concerns and services have received minimal attention; the new guidelines will work to change this.

Breaking down the stigma

The Canadian National HIV Pregnancy Planning Guidelines state, “Good pregnancy planning for HIV-positive people requires that they access health services to assist them in dealing with the medical and psychological issues involved, but this, in turn, requires disclosure.”

Unfortunately, despite technological and informational advances in HIV treatment, the stigma surrounding the virus is still a major concern. “Within the context of HIV, additional burden is placed on the HIV-positive individual or couple due to stigma and discrimination surrounding the disease and the risks of transmission,” says Margolese.

 As a result, many HIV-positive individuals are still not sharing their status out of fear that they will be treated differently by medical professionals who don’t have direct experience with the virus.

“An important aspect of the guidelines is the breakdown of stigma surrounding HIV and pregnancy,” explains Margolese. The guidelines will be put in place to ensure that every health-care professional is well-equipped with the resources to assist in successful pregnancy planning for couples and individuals living with HIV.

Safe conception with HIV

With the advancements of medicine and knowledge surrounding HIV infection, there are options available to all types of couples interested in planning a pregnancy free from both vertical transmission (from mother to baby) and horizontal transmission (from one partner to another).

Margolese advises HIV-positive couples or individuals to consider the risk of horizontal transmission before engaging in the pregnancy planning process. Studies have found that without the intervention of combined antiretroviral medications, the risk of transmission from an HIV-positive woman to an HIV-negative man is reported to be 0.03 to 0.09 per cent per act of intercourse, which is lower than the 0.1 to 0.3 per cent risk for male to female transmission.

With the aid of HIV drug treatment and fertility plans, the risk of vertical transmission from woman to child is less than one per cent, with a 0.5 per cent chance of the baby being positive. This rate is based on studies where women took recommended HIV treatments (often combination antiretroviral therapy, or cART) during pregnancy, delivered by C-section, and avoided breastfeeding. Margolese describes the five basic relationship situations and the fertility options available to minimize horizontal transmission of the HIV infection during preconception and conception stages. These cases are all outlined in the guidelines. In all situations, options are based on the HIV status of the partners.

1.       HIV-positive women with an HIV-negative male partner:

  • For these women, home insemination with her partner’s sperm is recommended. Home insemination involves the use of a device to insert the sperm into the vagina.
  • This procedure can be performed without the help of a fertility consultant, however if this proves unsuccessful for three to six months, it is recommended that the couple seek professional help.
  • It is not recommended that partners engage in unprotected sex.

2.       HIV-positive women with a same-sex partner or without a partner:

  • For women in this situation, it is recommended that they be referred to a fertility specialist and consider the option of intrauterine insemination with HIV-negative donor sperm.
  • This option is preferred to home insemination due to the increased success rate of intrauterine insemination performed by a fertility clinic.

3.       HIV-positive man with an HIV-negative female partner:

  • The safest method for these couples is sperm-washing with intrauterine insemination.
  • The process of sperm washing rests on the premise that the HIV resides in the semen of the HIV-positive male. The procedure includes the separation of the sperm from the semen, and the intrauterine injection of the HIV-free sperm into the HIV-negative female partner.

4.       HIV-positive man with a same-sex partner or without a partner:

  • The safest procedure for these couples and individuals is a combination of spermwashing and intrauterine insemination with a surrogate.
  • Seeking help from a fertility clinic is advisable.

5.       HIV-positive woman with an HIV-positive male partner:

  • Depending on the health situation of the partners, they can consider unprotected sex.
  • The guidelines suggest timed natural conception (based on the woman’s ovulation) for those taking combination antiretroviral therapy with fully suppressed HIV plasma viral loads.
  • With unprotected sex, there are risks for HIV superinfection and transmission of drug-resistant strains of HIV.

The management of HIV in pregnancy planning requires many special considerations, however mothers should not forget about general pregnancy planning recommendations. If any of these methods prove to be unsuccessful, the National HIV Pregnancy Planning Guidelines suggest considering adoption.

Despite the many advances in technology and the many conception options available to HIV-positive individuals and couples, Margolese explains that many barriers to receiving care still remain.

“Sperm washing is only available in 26 per cent of clinics in only four provinces,” says Margolese. “Furthermore, HIV fertility care may not be covered by provincial health care or private health insurance coverage.” Expensive fertility treatments are therefore inaccessible to many HIV-positive couples and individuals interested in starting a family.

The guidelines were published in the June 2012 issues of the Journal of Obstetrics and Gynaecology Canada.

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