Written by Samantha Hyacinth with support from The Well Project
By the end of 2019, about 1.2 million people aged 13 and older were living with HIV in the United States.¹ Because HIV is transmitted mainly via sex and injection drug use, it carries more stigma than other chronic diseases. People living with HIV are unfairly portrayed as hypersexual beings who should cease all sexual activity to promote public health. Thankfully, current advancements in antiretroviral (ARV) treatment and pre-exposure prophylaxis (PrEP)² have given those living with HIV the resources necessary for healthy, satisfying sex lives. These same advances eliminate the need to rely on condom use and/or abstinence to prevent HIV transmission. ARV medication can suppress a person’s viral load to undetectable levels, preventing people from passing HIV on to their partners.* In relationships where only one partner has HIV, PrEP provides another tool to prevent HIV transmission. Currently, the FDA has approved three medications for PrEP.²**
In a world where we can prevent HIV transmission by suppressing a person’s viral load and/or providing their partners with PrEP, people living with HIV should be free to enjoy condomless sex with their HIV-negative partners for any reason they choose, including becoming pregnant. When providing preconception counseling to someone living with HIV, discuss the steps they can take to conceive while reducing their risk of transmitting HIV to their partner and their baby. Key topics include:
- Can conceive through penile-vaginal intercourse if desired, although assisted reproductive technology may be needed in the cases of limited fertility.
- U=U: An undetectable viral load means HIV is untransmittable to their partner.
- PrEP options for the partner without HIV
- An undetectable viral load also prevents a pregnant person from transmitting HIV to the baby in utero.³ ARV medications may need to be adjusted during pregnancy for fetal safety.⁴
- With a low enough viral load, a person who desires can deliver vaginally, although a C-section may be needed in cases where the viral load is high during labor.⁴
- A baby whose birthing parent is living with HIV will need to take HIV medication for 4-6 weeks after birth.³
The conversation on whether to breast/chestfeed is nuanced. Clinicians should approach patients with respect to gain an understanding of their feelings and concerns. It’s important to present the existing data and discuss risk reduction techniques for those who wish to breast/chestfeed. Since there is a possibility that a person living with HIV could transmit HIV through their milk, the CDC,⁵ American Academy of Pediatrics,⁶ and the Office of AIDS Research⁷ do not currently recommend that anyone living with HIV breast/chestfeed; they do still recommended that anyone with the desire to breast/chestfeed be given appropriate harm reduction measures, such as:
- For patient: ARV therapy to maintain undetectable viral load for breast/chestfeeding patients
- For infant: ARV prophylaxis & routine monitoring for HIV acquisition
Resources for Clinicians
- Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States
- Counseling and Managing Individuals with HIV in the United States Who Desire to Breast/Chestfeed | NIH
- Clinicians with questions about breast/chestfeeding or other perinatal concerns can contact National Perinatal HIV Hotline (1-888-448-8765) for support
*To date there have been three large global research studies looking at data from over 3000 serodiscordant same-sex and opposite-sex couples showing that those with an undetectable HIV viral load do not pass HIV on to their partners. HTPN 052 Clinical Trial; PARTNER; Opposites Attract
**Two once-daily oral medications: emtricitabine / tenofovir disoproxil fumarate, emtricitabine / tenofovir alafenamide, and a new injectable given every two months cabotegravir. Due to a lack of data on its ability to prevent HIV acquisition in people having receptive vaginal intercourse, emtricitabine / tenofovir alafenamide has only been approved for people assigned male at birth.
The Well Project Resources:
1. Centers for Disease Control and Prevention. Estimated HIV incidence and prevalence in the United States, 2015–2019. HIV Surveillance Supplemental Report 2021;26 (No. 1). http://www.cdc.gov/hiv/
4. Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Transmission in the United States. Available at https://clinicalinfo.hiv.
6. COMMITTEE ON PEDIATRIC AIDS, Lynne M. Mofenson, Patricia M. Flynn, Grace M. Aldrovandi, Ellen Gould Chadwick, Rana Chakraborty, Ellen Rae Cooper, Heidi Schwarzwald, Jaime Martinez, Russell B. Van Dyke; Infant Feeding and Transmission of Human Immunodeficiency Virus in the United States. Pediatrics February 2013; 131 (2): 391–396. 10.1542/peds.2012-3543
7. Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at https://clinicalinfo.hiv.
For the months of June, July, and August, RHAP will be working alongside The Well Project to create a summer “string of pearls” series on HIV care and preconception, contraception, and screening.
The Well Project is a non-profit organization whose mission is to change the course of the HIV/AIDS pandemic through a unique and comprehensive focus on cis and trans women and girls. The Well Project envisions a world in which women living with or vulnerable to HIV have the information, support, and tools they need to advocate for their health and well-being, and live free from stigma.
Founded in 2002, The Well Project has become a recognized leader in the fight against HIV by revolutionizing the availability and accessibility of much-needed resources designed specifically for women living with and vulnerable to HIV and by prioritizing the advancement of women in all aspects of HIV prevention, treatment, and cure research and policy.
The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or contraception. The information in the Contraceptive Pearls is unbiased, based on science alone.