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Fertility and HIV. Vivian Black WITS Reproductive Health and HIV Institute, South Africa 26 July 2012. Fertility Desires. HIV infected women and men desire children ART initiation increases fertility intention Desire for children changers with time and life events

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fertility and hiv

Fertility and HIV

Vivian Black

WITS Reproductive Health and HIV Institute, South Africa

26 July 2012

fertility desires
Fertility Desires
  • HIV infected women and men desire children
  • ART initiation increases fertility intention
  • Desire for children changers with time and life events
  • Focus on women, yet males want children and influence their partners

Badell ML et al. Infect Dis ObsteGynecol , 2012

Dyer SJ. J Psychosom Obstet Gynaecol , 2007

Schwarts SR et al AIDS Behav, 2011

Schwarts SR et al PLoS One, 2012

fertility intentions and incidence
Fertility Intentions and Incidence
  • 850 HIV infected women on ART, aged 18-35 years, were from 4 PEPFAR supported ART sites in inner city Johannesburg, September 2009 – March 2011

Schwartz SR, et al AIDS Behav 2011

Schwarts SR et al PLoS One, 2012

contraceptive use amongst 748 women on art not trying to conceive
Contraceptive use amongst 748 women on ART not trying to conceive

Consistent Condoms: 54%

HormonalContraception: 32%

Dual Use: 15%

Unmet Need: 29%

Schwartz SR, et al AIDS Behav 2011

fertility desire and contraception uptake usa
Fertility desire and contraception uptake - USA

Atlanta ID Clinic surveyed 127 HIV positive women 18-50 years.

  • High rates of sterilization, 44% (18% of whom desired children), 56% were sterilized because they were HIV infected.
  • Condom use 41%
  • Low rates of hormonal contraception

Badell ML et al. Infect Dis ObsteGynecol , 2012

patient provider communication
Patient-provider communication
  • Patient-provider communication about fertility is an important part of HIV prevention
patient provider communication1
Patient-provider communication


  • Only half of women had spoken to their HCW about contraception in previous year
  • 1/3 had never/not in 5 years spoke to their HCW about contraception
  • Less than half of women believed IUCD, hormonal contraception was safe


  • Nearly all women (93%) reported that a HCW had discussed condom
  • Only 48% of women reported that an HIV provider had discussed non-barrier methods
    • HC use was higher in women whose HCW had discussed HC methods (37% vs. 21%, p<0.01)

Badell ML et al. Infect Dis ObsteGynecol , 2012

Schwartz SR, et al AIDS Behav , 2011

consequences of poor communication
Consequences of poor communication


  • Half of all pregnancies in the US are un-intended.


  • 170 pregnancies documented in 161 women,
  • 105 (62%) were unplanned
  • 56 (53% ) were EFV conceptions
  • Of these 36 (36%) elected TOP

Schwartz SR, et al PLoS ONE 2012

special groups
Special Groups

Perinatally Infected Women/Youth

  • UK Ireland cohort of 252 women >12 year
  • 42 pregnancies among 30 women
  • Median age 18 (14-22 years)
  • 81% unplanned
  • >50% of partners unaware of HIV status
  • 36% elected termination of pregnancy
  • 33% had detectable VL
  • 1/21 infants infected with HIV

Kenny J et al. HIV Med 2012

special groups1
Special Groups

Couples struggling to conceive may increase risky sexual behavior such as multiple partners

Same sex relationships

Dhont N, et al . Sex Transm Infect 2011

towards a solution
Towards a Solution
  • Health care workers working with HIV infected people need to talk to their patients about fertility intentions regularly.
  • Integration of family planning services into HIV services.
different approaches to supporting fertility in hiv infected couples
Different approaches to supporting fertility in HIV infected couples
  • Resources Available
  • Resources Not available

Infected woman





Infected woman

Uninfected woman



Uninfected woman



Infected woman







pre conception counselling
Pre-conception counselling
  • Reasons for reproductive desire
  • Disclosure of status
  • Reproductive options, including risks, risk reduction, costs and chances of success
  • Balance the risk of natural conception with established risk-reduction methods
  • Consequences of failure to prevent transmission to partner and child and importance of regular testing
  • Health of infected partner and woman
minimum pre conception medical assessment
Minimum pre-conception medical assessment
  • Exclude STIs through syphilis serology and clinical assessment
  • Exclude AIDS: Medical examination and CD4 cell count
  • Those on ART should have an undetectable VL
  • Screen for infertility through history
  • Pregnancy: RH, haemoglobin
medical management
Medical management
  • Optimise medical condition
  • Treat any current infection
  • Treat co-morbid illnesses
  • Determine ovulatory cycle
fertility and hiv1
Fertility and HIV

Scenario 1: Negative woman and positive man

  • The man should be on ART and have suppressed viral load
  • Assisted techniques – sperm washing , insemination

OR in “Resource limited” settings

  • The couple practice safe sex for most of the woman’s cycle using condoms.
  • Use ovulatory method and have sex without condom on alternate days during ovulation
criteria for natural conception
Criteria for Natural Conception
  • The responsibility of adherence rests with HIV positive partner
  • The decision of consenting to unprotected intercourse lay with the HIV negative partner
  • Limited to 6 months during ovulation period only
  • Condoms should be used at all other times
    • HIV positive partner on ART for ≤ 6 months
    • VL undetectable
    • Perfect adherence to treatment and medical follow-up
    • Mutually faithful relationship
    • No concomitant STI

Barreiro, Human Reproduction 2007

fertility and hiv2
Fertility and HIV

Scenario 2: Positive woman and negative man

Ideally woman on ARTs with suppressed viral load

  • No need to expose man to risk of becoming HIV infected
  • Conception: sperm collection with insemination at the time of ovulation
    • Man ejaculates in clean receptacle
    • Semen drawn up into a large syringe (10 - 20ml)
    • Syringe placed about 4 – 6 cm in woman’s vagina in prone position and semen pushed out of the syringe
    • Can be done at home or in clinic.
fertility and hiv3
Fertility and HIV

Scenario 3:Concordant positive couple

  • Optimise health
  • Ensure not on any teratogenic drugs
  • Risk of horizontal transmission not a concern
  • Vertical transmission needs to be considered
  • Natural conception
  • After attempting 6 ovulation cycles unsuccessfully, consider reduced fertility. Risk of continuing naturally exposes the partner to risk of HIV infection and may not result in conception
  • Counsel and if appropriate refer for further work-up
  • Repeat HIV testing of exposed partner

Repeated HIV antibody testing for exposed partners

  • If woman seroconverts during pregnancy, provide ART as soon as possible as seroconversion is associated with high rates of mother-to-child transmission
important to protect partner after conception
Important to protect partner after conception

Increased risk of HIV-1 transmission in pregnancy: Prospective study among African serodiscordant couples

  • HIV viral load in genital secretions during pregnancy is increased
  • Increased risk of HIV transmission

from a pregnant woman to her sexual


Mulago NR et al, AIDS 2011

  • If woman HIV infected, ideally she was on ART prior to conception. She should continue ART throughout pregnancy.
  • If the woman was not on ART, provide ART if feasible (guideline limitations in some settings), or else provide PMTCT as per local guidelines.
thank you


Further Reading

Bekker L-G, Black V et al. Guideline on Safer Conception in Fertile HIV-infected individuals and couples. The Southern African Journal of HIV Medicine, June 2011.

New York State Department of Health. Preconception Care for HIV-infected Women. Guideline summary NGC 8022: New York State Department of Health.

Fakoya A, Lamba H et al British HIV Association, BASHH and FSRH Guidelines for the Management of the Sexual and Reproductive Health of People living with HIVinfection2008. HIV Med 2008; 9: 681.

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