POZ Community Forums
Main Forums => Living With HIV => Topic started by: Cliff on November 08, 2006, 04:40:03 pm
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I just saw this report. It seems like it would be a short leap from the assumption that if Natural Conception is potentially safe for mixed-status couples (with undetectable viral load), then it might be for others in similar, albeit not trying to conceive a child, situations. Of course the two scenarios aren't necessarily similar, but one could easily make that jump.
Natural Conception Potentially Safe for Mixed-Status Couples
By Tim Horn, Senior Writer & Editor, AIDSmeds.com
A new report suggests that natural conception may be a safe option for heterosexual couples in which one partner is HIV positive and the other is HIV negative. The conclusions of the Spanish study reported in the November 1 issue of the Journal of Acquired Immune Deficiency Syndromes suggest that unprotected vaginal intercourse to achieve pregnancy, provided that the HIV-positive partner is on HIV drug treatment and has an undetectable viral load, may be associated with a minimal risk of HIV transmission.
For people living with HIV today, pregnancy is no longer the medically and ethically challenging situation it once was. For starters, antiretroviral treatment can potentially extend an HIV-positive person's life by decades, making 18-plus years of child rearing a possibility. Second, HIV-positive mothers-to-be can drastically reduce their risk of transmitting the virus to their babies to less than 2% with proper use of HIV treatment during pregnancy.
A lingering challenge faced by many couples affected by HIV especially those in which one partner is HIV positive and the other is HIV negative wanting to become pregnant is the best way to go about conceiving. Given that natural conception unprotected vaginal intercourse may put the HIV-negative partner at risk for infection through exposure to his or her HIV-positive partner's genital fluids, many mixed-status couples have turned to artificial means for assistance. For example, there's "sperm washing" and in vitro fertilization, two expensive and time consuming options. There are also crude and highly unreliable at-home protocols calling for artificial insemination with the use of turkey basters and other utensils.
Previous studies have documented that HIV-positive people with "maximally suppressed" virus while on HIV drug treatment are significantly less likely to pass their virus along to their sexual partners. In turn, a team of Spanish researchers took a look at the transmission risk associated with natural conception among mixed-status couples, in which the HIV-positive partner had an undetectable viral load as a result of antiretroviral therapy.
The study reviewed the files of 62 mixed-status couples who opted to conceive naturally between 1998 and 2005. The HIV-positive partner was the man in 40 (65%) cases and the woman in 22 (35%) cases. The average viral load, at the time of conception, was less than 500 in both the male and female infected partners. All HIV-positive mothers had undetectable viral loads at the time of delivery.
A total of 76 pregnancies among the 62 couples were documented during the seven-year period. Fifty-two couples had only one pregnancy during this time, six couples reported two pregnancies, and four couples had three pregnancies. There was one case of twin pregnancies and nine miscarriages (which were more common among the HIV-positive women than the HIV-negative women).
The authors reported that, in all cases, the HIV-negative partner remained uninfected.
There was, however, one case of mother-to-child transmission. Even though HIV treatment was used to reduce the risk of infection, a baby born to a 37-year-old HIV-positive woman was diagnosed with AIDS-related Pneumocystis pneumonia (PCP) during the third week of life and subsequently died.
Aside from their conclusion that mixed-status couples "attaining natural pregnancy are exposed to a negligible risk of sexual transmission of HIV when the infected partner [has an undetectable viral load] while on [HIV drug treatment]," the researchers also provided some useful conception recommendations.
"If the couple has opted for natural pregnancy," they write, "undetectable viremia is mandatory and pregnancy is discouraged in patients with any levels of HIV replication." They add that other transmissible infections (e.g., viral hepatitis), cofactors that can increase the risk of transmission (e.g., inflammation, infection, or dysplasia of the genital tract), and fertility potential should all be evaluated carefully before attempting natural conception. Finally, "it is important to advise these couples to restrict overt sexual contacts to fertile days exclusively, for which the use of ovulation tests may be recommended. Pregnancy attempts should be limited in number, and couples should receive medical reassessment if conception does not occur in three to six months."
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Good post.
Where is the study on transmission or not of HIV via anal sex for people with low/undetectable viral loads (cos that is the question ain't it?) Jump? I made it, and so has everyone I know (all the neg people still neg).
- matt
Now playing: Pink Floyd, Brain Damage
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PS - the new BHIVA (British HIV Association) guidelines on Sexual and Repoductive Health are very downbeat about the risk of reinfection between +ve people not using condoms. Bout time too.
- matt
Now playing: Pink Floyd, Us and Them
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I wish they made it clearer, though. I would want to separate out the hiv positive men with hiv negative women and their experiences versus hiv negative men with hiv positive women and their experiences which was sort of there in the report but sort of not that. We think we know that it is less likely for an hiv negative man to become infected from an hiv postive woman than the reverse but that, too, may depend upon ciircumcision. And I do recall other studies which suggested that even if the virus is suppressed, it is still able to transmit from postive to negative, but again, who is and who isn't, to Matt, and who is top and who is bottom (with unprotected anal sex). Win
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When they use the word, "MAY", that is the catch 22 statement.
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I posted the Spanish article a few weeks ago:
http://forums.poz.com/index.php?topic=3947.0
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An interesting question. I just read this today.
Peter Leone writes in this months NC Medical Journal:
"Transmission of HIV is principally driven by the quantity of the HIV inoculum in either blood or genital secretions......Therapy with ARV (anti retrovirals) can precipitously drop the serum and genital secretion viral load and potentially render the individual "non-infectious" should the viral load drop below detection."
-NC Med J Sept/Oct 2006, Volume 67, Number 5
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PS - the new BHIVA (British HIV Association) guidelines on Sexual and Repoductive Health are very downbeat about the risk of reinfection between +ve people not using condoms. Bout time too.
Yes, bout time. At THT training they spent so much time focusing on the risk of reinfection, as if it was a done deal. And all the folks (negative assuming) were harping on that issue, while a small minority of folks weren't convinced that it was a big deal (positive assuming).
I hope these, and other (much needed) studies, starts to add some weight to the assumptions many positive folks have come to accept, that there is definintely some benefit to exposure if a person is undetectable and the risk of reinfection is pretty rare.
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At the risk of being long-winded, this is what BHIVA plan to say about risk of superinfection for people with chronic (longer than 3 years) HIV infection:
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Risk for superinfection in chronic HIV infection
To date, no apparent superinfection cases have been reported among chronically infected individuals - either untreated or on antiretroviral therapy.
Gonzales and colleagues [15] looked for superinfection in 718 people - representing 1072 person-years of follow-up - in a clinic cohort, the majority of whom were on antiretroviral therapy found no evidence of it. However, no data on continued HIV exposure was reported.
Tsui and colleagues documented high-risk behaviour among injecting drug users (IDUs) over 215 person-years of observation and also found no evidence of superinfection.[16].
Grant and colleagues [17] found no evidence of superinfection among HIV-positive couples with genetically distinguishable virus at baseline after 233 person-years of follow-up, representing an estimated 20,859 exposures during unprotected anal or vaginal intercourse. Based on self-reported risk behaviour, they calculated that they would have expected to see 89 new infections during this time if one of the partner has been HIV-negative.
Taken together, these data suggest that initial HIV infection provides protective immunity against superinfection in chronically infected individuals, regardless of antiretroviral therapy or exposure risk.
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References, and full text on this topic in draft BHIVA Sexual and Reproductive Health Guidelines (http://www.bhiva.org/pdf/2006/bhivasexualhealth06.pdf) [920 Kb PDF file].
This is a bit off-topic. If people wanna discuss superinfection (again) maybe we's better off with a new thread...
- matt
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There are ethical considerations when thinking of having a baby when +.
How does one live with the knowledge that they passed the virus on to their child? What happens if one or both parents pass away? Is it fair to bring a child into a family which has to deal with a chronic illness? Could one raise a child while being ill? Are there going to be any long term effects of the mother/father using HAART?
Just some of the questions I have struggled with over the past years.
Christine
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Christine, that can happen with many other diseases. Downs Syndrome, CF, etc., etc. to name just a couple.
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Cancer is also a chronic illness and cancer patients usually have children. My friend Rose had breast cancer and has decided to have a child. She has many chances of having cancer again, but she has the right to have a fullfilling life and she is going to be a wonderful mother.
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Matt,
Thanks for the I-base. The only thing I thought about was what are the chances that reinfection does occur but it doesn't have any clinical significance....which could also explain why it goes unnoticed.
Christine,
I agree that there are considerations (ethical or otherwise) in deciding on whether or not to have a child. But I don't think those issues necessiarily mean that someone who is HIV positive can't be a parent. Some may choose to have a child, others may not.
I really don't see any of these issues being completely unique to HIV, other than the risk level being higher (in some cases). All parents have to decide what will happen to their child, should they die. Plenty of people have children in not-so-optimal living arrangements (at least on paper)...whether it be because they are single, poor, work too much, live in a loveless marriage, etc.. I suppose one could argue that it's not fair to bring a child into those environments as well.
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Hello again. I have had 3 children since finding out I was positive. Well actually my daughter was positive and that's how I found out. But ALL om my children are negative from evrything. Medicine has come a LONG WAY[/size
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hmm as a hiv + pregnant woman who is also a cancer survivor I just have to say I would rather hear you are HIV pos again than your cancer is stage 4 again.
That being said, I talked with my partner about keeping this pregnancy after we found out I was positive. We both came to the conclusion that with meds and the advances that they are making in research of this disease I should be around for a long time. Did anyone censure Lance Armstrong for having more children after his battle with cancer? I realize that we are all entitled to opinions and ethics on here it is just that I felt a little OUCH. I am thick skinned though and know that I am doing the right thing for me and my family. At least if something happens to me my two year old will have the bond of another sibling.
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I will add that colon cancer clearly runs in my family. My father's father died of it. My father had a colostomy as did a second cousin of his (if this is the right term for the operationi which reroutes things). My brother decided not to have children because of the likelihood of either having the gene himself or of passing it along to a next generation. This is off, a bit, from where things started in this thread, but as we gain more knowledge about what we 'carry' inside us, should everything other than perfect health keep us from having children? If someone has hiv, it may or it may not be passed along to a child. Ditto, if someone has cancer, it may or may not be passed along to a child. Ditto blue eyes, brown eyes, height, etc. I think that the ethical decision is one made by people who are using all the information that they have in front of them and that this information may include 'there is a possibility of passing this to your child.' Win
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Hello All,
I agree with all of you have posted. Any illness can present concerns for a couple deciding to have children. I apologize if my post hurt feelings, or sounded judgemental. I absolutely did not intend for that.
I was just stating my feelings and concerns that my husband and I have struggled with over the past 14 years. It has not been easy. It is hard when your dream of your life; getting married, having children, growing old together...changes with one statement, "your test came back positive".
We decided to not have children. Do I second guess if this was the right choice or not? Almost everyday, and everytime I am around beautiful babies.
Christine
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Christine,
A sweet lady like you does not need to apologize. I understand what you mean. People usually have to have a guaranteed future before having children. That is being reponsible.
But we can also die in a car accident anytime. As I always say to myself "being alive is being in constant danger of death".
I apologize to you if my answer sounded rude to you. I am rude sometimes but my way of thinking has changed since diagnosis. I am sure you made a wise decision. In fact I should never discuss this subject because I don΄t like children, I will never feel responsible enough to raise them and I will never have the chance to have them.
Your opinion has much more value than mine.
Kisses.
Juan
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Some of us were already discussing this:
http://forums.poz.com/index.php?topic=5598.0
In which I posed the question,
Is this article advocating barebacking?
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Hello All,
I agree with all of you have posted. Any illness can present concerns for a couple deciding to have children. I apologize if my post hurt feelings, or sounded judgemental. I absolutely did not intend for that.
I was just stating my feelings and concerns that my husband and I have struggled with over the past 14 years. It has not been easy. It is hard when your dream of your life; getting married, having children, growing old together...changes with one statement, "your test came back positive".
We decided to not have children. Do I second guess if this was the right choice or not? Almost everyday, and everytime I am around beautiful babies.
Christine
You have to decide what answer is right for you. I believe that an HIV positive woman has the right to have children as much as anyone. I know a lot of people who single HIV positive people out when they mention ethical dilemmas. But I guess, what level of risk are you comfortable with? We are lucky to live in the western world, where we have access to treatment. If we get treated, are followed with a knowledgable doctor, get treated during labor or have a C-section, don't breastfeed, the child gets prophylactic treatment, it is unlikely we'lll pass HIV to our babies. The risk is much less than many other things out there that the baby can get because of genetics. I know of a couple who both are carrier's of Tay-Sachs disease--that gives them a 25% chance of having a baby with the disease, but they took the risk and have two healthy children. Or about cancer, diabetes, heart disease that run in the family--people with those histories have children ever day. Those with HIV are not any less worthy to have children. Also, adoption is an option for those who want it. I am still at that stage where I like it when I can hand a baby back to its mother, but I have decided to keep the children option open.
As for a parent being sick--I also know of a woman with advanced stage breast cancer who continued on with her pregnancy against the advice of her doctors. She is much more likely to die than me. But everyday, we can die--we can get in an accident, we can be hit by a car while getting mail.
Anyhow, the decision comes down to the person. Whether they decide to have children or not, no one should apologize for their decision. You shouldn't either.
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Those with HIV are not any less worthy to have children. Also, adoption is an option for those who want it.
I was first diagnosed in '93 when I was 27. At that time having children was not as safe of an option. And adoption was not possible (as far as I knew) for an hiv + person. So that is the perspective that I am looking through.
I was counseled by my case worker and doctor on how to avoid pregnancy. The risk of transmission at that time was much higher than it is now.
Now 13 years later at 40, hiv has effected my menstrual cycle so I am in the peri-menopausal stage of life. Pregnancy is no longer an option.
I think it wonderful that at this point in hiv care, there are so many options for couples. Had they been there in '93 my life might be very different.
All that being said, I still think there are questions that one needs to ask themselves before deciding to have children.
And I was not apologizing for my opinion, but for any possible hurt feelings I may have caused.
Christine
edited for grammar