In HIF/HUM serodiscordant couples, there are three unique clinical challenges: maintaining the woman's health before, during, and after the pregnancy; preventing perinatal transmission; preventing sexual transmission to the HIV negative partner [16
]. In order to facilitate conception and a safe pregnancy, the health of both members of the couple should be optimized. The HIV-infected woman should have a thorough clinical assessment (CD4 count, viral load, and genotype if available), evaluation of antiretroviral regimen, identification and management of comorbidities such as tuberculosis, diabetes, or hypertension in addition to other transmissible infections or cofactors that may increase the risk of HIV transmission or acquisition [10
]. Similarly, an HIV-infected person should be counselled on the risks of conception with a detectable HIV-1 RNA viral load, documented infertility or presence of conditions affecting fertility in either partner, nondisclosure of HIV status, or medical contraindications to pregnancy [12
]. In couples with documented infertility, they may be referred to a fertility clinic for preconception counseling and discussion of available options, if available. If either partner has conditions affecting fertility the couple can be allowed to continue their attempts at conception; however, they should be encouraged to seek assisted reproductive technology services after six unsuccessful attempts at vaginal insemination or timed unprotected intercourse over six cycles [12
]. Couples should also have a clinical assessment to screen and treat for sexually transmitted infections prior to attempts at conception [12
]. In eligible HIV-infected women, antiretroviral therapy (ART) should be initiated and optimized to improve their health status and reduce the risk of HIV transmission [23
]. The use of combination antiretroviral regimens in HIV-infected women is associated with a near elimination of perinatal HIV transmission [50
Male circumcision, ART, timed unprotected intercourse, PrEP for the uninfected male partner, and vaginal insemination of semen during the fertile period can be used in concert for HIF/HUM desiring conception. For example, an HIF on ART may attempt timed unprotected intercourse or vaginal insemination with her HUM partner that has been circumcised. Together, these low-cost interventions may allow HIF/HUM serodiscordant couples to safely conceive while decreasing the risk of sexual HIV transmission.
Preventing sexual transmission of HIV to the uninfected partner involves counseling on the consistent use of condoms with all sexual encounters while attempting to conceive with timed unprotected intercourse, PrEP, assisted reproductive technology, or vaginal insemination. Despite these recommendations, the barriers to consistent condom use should not be overlooked. Difficulties that have been reported with consistent condom use include loss of spontaneity, reduced libido, and decreased frequency of sexual intercourse [17
]. However, healthcare providers can help HIV serodiscordant couples overcome these challenges with an emphasis on their motivation to safely conceive and minimize sexual HIV transmission. It has been argued that couples and medical providers accepting the risk of transmitting a disease to their offspring do not act unethically if all reasonable precautions to prevent transmission are taken [33
As the paradigm shifts to assisting HIV-affected couples fulfill their reproductive goals of procreating, healthcare providers must also begin to expand their understanding of the family planning concept beyond contraception to include methods of safer conception. This more comprehensive concept of reproductive healthcare also includes safer methods of conception. The integration of comprehensive reproductive healthcare services into HIV care and treatment programs will strengthen the repertoire of medical services available to HIV-affected couples desiring children.