Periconception pre-exposure prophylaxis to prevent HIV transmission: benefits, risks, and challenges to implementation

Abstract

HIV-serodiscordant couples face complicated choices between fulfilling reproductive desire and risking HIV transmission to their partners and children. Sexual HIV transmission can be dramatically reduced through artificial insemination and sperm washing, however most couples cannot access these resources. We propose that periconception pre-exposure prophylaxis (PrEP) could offer an important, complementary therapy to harm reduction counseling programs that aim to decrease HIV transmission for couples who choose to conceive. In this paper we describe the potential benefits of periconception PrEP and define critical points of clarification prior to implementation of PrEP as part of a reproductive health program. We consider sexual transmission risk, current risk reduction options, PrEP efficacy, cost, adherence, resistance, fetal toxicity, and impact of PrEP counseling on entry into health services. We address PrEP in the context of other periconception HIV prevention strategies, including antiretroviral treatment of the HIV-infected partner. We conclude that, should PrEP prove safe and efficacious in ongoing trials, periconception PrEP may offer a useful approach to minimize risk of HIV transmission for individuals of reproductive age in HIV-endemic countries.

Perspectives on HIV Prevention Among Urban Black Women: A Potential Role for HIV Pre-Exposure Prophylaxis

“…Socioeconomic factors that were explored included poverty and access to care. 33 Physical exposures manifest as behavioral risk factors including having one or more partners at high risk for HIV acquisition, 34 history of sexual abuse, 35 degree of perceived control, 33 current HIV risk perception and use of preventive interventions such as condoms, 11 and partner communication 36 Social norms included religious affiliations, 37 desire to conceive, 38 and lack of knowledge of HIV prevention strategies. 39 Discussions explored how these domains influenced acceptability of PrEP, preferred setting and provider type for accessing PrEP, 40 and hypothetical preferences for oral vs. topical PrEP administered as an intravaginal gel.…”

Fertility Decision-Making Among Kenyan HIV-Serodiscordant Couples Who Recently Conceived: Implications for Safer Conception Planning

“…[1][2][3][4][5][6][7][8] Yet in sub-Saharan Africa, where approximately 50% of couples with an HIV-infected partner are HIV-serodiscordant, these ''safer conception'' strategies are often unavailable or not discussed early enough with HIV-serodiscordant couples who desire children. 9,10 These couples would benefit from education and counseling about accessible and feasible safer conception strategies that protect HIV-uninfected partners during peri-conception (i.e., pregnancy attempts without condoms).…”

“…For African HIV-serodiscordant couples in low resource settings, feasible peri-conception risk reduction strategies may include limiting condomless sex to peak fertility periods, antiretroviral pre-exposure prophylaxis (PrEP) taken by the HIV-uninfected partner, antiretroviral treatment (ART) to suppress viral load of the HIV-infected partner, treatment of sexually transmitted infections, infertility screening, and/or vaginal self-insemination when the woman is HIV-infected. 3,[11][12][13][14] Prior to widespread delivery of safer conception interventions and counseling, it is important to understand how HIVserodiscordant couples approach fertility decisions in settings with high HIV prevalence. Safer conception interventions ideally involve both partners of an HIV-serodiscordant couple.…”

How the global call for elimination of pediatric HIV can support HIV-positive women to achieve their pregnancy intentions

“…68 Providing an HIV-negative partner with ARVs as pre-exposure prophylaxis has also been explored as a potentially effective strategy for preventing acquisition of HIV when attempting to conceive. 71 However, both of these interventions can be challenging in resourceconstrained settings where ARVs may not be widely available or where clinical guidelines restrict treatment to only HIV-positive individuals who are medically eligible for treatment. The WHO guidelines on couples HIV testing and counseling note that the use of ARVs for reasons other than treatment "raises complex issues for both individuals and programs" and that equity and human rights concerns must be weighed.…”