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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Curr Opin HIV AIDS. Author manuscript; available in PMC 2013 June 28.
Published in final edited form as:
PMCID: PMC3695736

Antiretrovirals and safer conception for HIV-serodiscordant couples


Purpose of review

Many men and women living with HIV and their uninfected partners attempt to conceive children. HIV-prevention science can be applied to reduce sexual transmission risk while respecting couples’ reproductive goals. Here we discuss antiretrovirals as prevention in the context of safer conception for HIV-serodiscordant couples.

Recent findings

Antiretroviral therapy (ART) for the infected partner and pre-exposure prophylaxis (PrEP) for the uninfected partner reduce the risk of heterosexual HIV transmission. Several demonstration projects suggest the feasibility and acceptability of antiretroviral (ARV)s as periconception HIV-prevention for HIV-serodiscordant couples. The application of ARVs to periconception risk reduction may be limited by adherence.


For male-infected (M+F−) couples who cannot access sperm processing and female-infected (F+M−) couples unwilling to carry out insemination without intercourse, ART for the infected partner, PrEP for the uninfected partner, combined with treatment for sexually transmitted infections, sex limited to peak fertility, and medical male circumcision (for F+M couples) provide excellent, well tolerated options for reducing the risk of periconception HIV sexual transmission.

Keywords: antiretrovirals as prevention, conception, fertility, HIV prevention, HIV-serodiscordance, perinatal HIV transmission, sexual HIV transmission


Studies in North America [1,2], Europe [35], and sub-Saharan Africa [610] report that 20–50% of HIV-infected men and women desire children. The contribution of intended conception to incident HIV infection is unknown, but likely represents a large proportion given high fertility rates and the importance of having children in most HIV endemic areas [1113]. In most sub-Saharan African countries, up to half of those living with HIV report a serodiscordant partner and estimates suggest that up to 60% of new infections occur between stable, heterosexual, serodiscordant couples [1416]. As men and women with HIV live longer, healthier lives, safer conception counseling for HIV-serodiscordant couples is a reproductive right [1719] and should be included as a public health strategy to reduce HIV incidence among men, women, and their children in settings with generalized HIV epidemics [20,21[filled square][filled square],22[filled square]]. Integrating effective HIV prevention strategies into comprehensive reproductive counseling is a rational step to protect uninfected partners and their children and to make progress towards eliminating HIV.

Several strategies allow HIV-serodiscordant couples to conceive with minimal transmission risk to the uninfected partner (Table 1) [2333,34[filled square][filled square],35, 36,37[filled square][filled square],38[filled square][filled square],39[filled square][filled square],4042]. For female-positive couples (F+M−), the safest option is vaginal insemination without intercourse (man ejaculates into a condom or cup and the contents are introduced via condom reversal or needle-less syringe) timed to peak fertility. This can be completed at home and confers zero risk to the male partner [43]. For male-positive serodiscordant couples (M+F−), laboratory techniques can isolate sperm (which do not harbor HIV) from seminal plasma and leukocytes [44]. ‘Washed’ or processed sperm can be introduced via intrauterine insemination or in-vitro fertilization with or without intracytoplasmic sperm injection [29,45,46]. Although there are no randomized, controlled trials (RCTs), sperm processing centers report 4638 M+F− inseminations, a 50% pregnancy rate, and no recorded HIV-transmissions [2831]. These findings suggest the process is safe and effective, but it remains challenging for most people to access due to costs and limited availability [4648].

Table 1
Strategies to reduce periconception risk of HIV transmission for serodiscordant couples

For M+F− serodiscordant couples, who cannot access sperm processing, and F+M− couples unwilling to carry out insemination without intercourse, vaginal intercourse without condoms coupled with adjunct risk reduction strategies can reduce HIV transmission while allowing for conception [4951]. Adjunct strategies include medical male circumcision (MMC) for F+M− couples [2527], treatment for STIs [40,41], limiting unprotected sex to peak fertility, and the use of ARVs-as-prevention (Table 1). Recent data indicate that antiretroviral therapy (ART) for the infected partner and pre-exposure prophylaxis (PrEP) for the uninfected partner may offer benefits for HIV-serodiscordant couples who choose to conceive. The purpose of this article is to review how ARVs-as-prevention can be incorporated into comprehensive reproductive health counseling for serodiscordant couples.

Incorporating risk reduction methods into a couple’s sexual practice requires mutual HIV testing and disclosure, understanding HIV transmission risks, knowledge of and access to risk-reduction strategies, a relationship in which sexual practices and reproductive decisions are considered, discussed, negotiated, and practiced, and ability to adhere to risk-reduction strategies [52[filled square]]. Mutually disclosed serodiscordant couples, who carry out equitable discussions about sex, conception, and family planning are likely a rare population [5355]. We apply the data to the context of mutually disclosed serodiscordant couples while acknowledging that prior to offering safer conception strategies, mutual HIV-testing, disclosure, and communication must be supported as an essential first step in any reproductive counseling program [21[filled square][filled square],52[filled square]].

Antiretrovirals for prevention

We present data supporting the use of ART for the infected partner and antiretroviral PrEP for the un-infected partner as HIV prevention for heterosexual discordant couples, demonstration projects which apply these strategies to periconception risk, and make recommendations for the use of ARVs for prevention for serodiscordant couples who choose to conceive.

Data supporting antiretroviral therapy for the infected partner as prevention

Observational data first published over a decade ago show that low plasma HIV RNA is associated with decreased sexual HIV transmission [36,56,57]. ART for the infected partner was associated with a 92% reduction in HIV-acquisition risk among uninfected partners in a secondary analysis of the Partners in Prevention Trial [35] and ecologic data show an association between lowering community-level viral load (through increased testing and treatment) and decreased HIV incidence [58,59].

In the HIV Prevention Trials Network Study 052, 1763 mutually disclosed HIV-serodiscordant couples in which the infected partner had a CD4 cell count between 350 and 550 cells/mm3 were randomized to ART at enrolment or upon decline in CD4 to 250 or fewer cells per μl or onset of AIDS-defining illness. Early therapy was associated with a 96% reduced risk of genetically linked transmissions [34[filled square][filled square]]. For couples who attempt natural conception, delaying sex without condoms until the infected partner is on ART with a suppressed plasma viral load can dramatically reduce HIV transmission.

Data supporting oral or topical pre-exposure prophylaxis for the uninfected partner

With PrEP, an HIV-uninfected individual uses antiretroviral medications continuously or before and after exposure to minimize HIV acquisition. In CAPRISA-004, high-risk HIV-uninfected heterosexual women randomized to pericoital 1% tenofovir vaginal gel versus placebo had a 39% reduction in HIV acquisition [60[filled square][filled square]]. Conversely, the Microbicide Network VOICE trial arm of tenofovir gel was halted due to lack of efficacy; details are not yet available. An additional efficacy study of pericoital tenofovir gel is enrolling and alternative topical antiretrovirals are under investigation (

In the first completed placebo-controlled trial of oral, daily emtricitabine/TDF(FTC/TDF) as PrEP, HIV acquisition was reduced by 44% among HIV-seronegative men or transgender women having sex with men [61]. In the Partners PrEP trial, HIV acquisition was reduced by 67% and 75% among HIV-serodiscordant couples taking oral TDF or FTC/TDF, respectively, without significant differences by sex [37[filled square][filled square]]. Having detectable drug levels was associated with 86% risk reduction for TDF and 90% risk reduction for those in the FTC/TDF arm. In the CDC TDF2 trial, HIV acquisition was reduced by 63% among men and women taking daily FTC/ TDF [38[filled square][filled square]]. In contrast, the FEM-PrEP trial of daily FTC/TDF and the VOICE trial arm of oral TDF for heterosexual women were halted for futility [39[filled square][filled square],62,63]. These divergent findings may relate to adherence [39[filled square][filled square],64] and qualitative data from partners PrEP participants, who had high adherence, suggest stable serodiscordant couples were motivated to adhere to PrEP in order to preserve the relationship [65[filled square][filled square]]. These data support the application of daily, oral PrEP to minimize periconception HIV transmission among uninfected men and women with an HIV-infected partner not eligible for, failing, or not taking ART. PrEP may further reduce periconception transmission when the infected partner has viral suppression on ART. These data informed the recent US Food and Drug Administration approval of FTC/TDF as PrEP for at-risk HIV-uninfected men and women [66].

Demonstrations of antiretrovirals-as-prevention for safer conception

Barreiro et al. [49] studied serodiscordant couples (40 M+F− and 22 F+M−) who attempted timed, natural conception while the infected partner was on ART (for at least 6 months), resulting in 76 pregnancies, 68 live births, 0 sexual transmissions, and 1 case of perinatal HIV transmission. Vernazza et al. [67[filled square][filled square]] followed 37 M+F− couples through 170 cycles of periovulatory unprotected intercourse while the infected partner was on ART and the uninfected partner was taking tenofovir or FTC/TDF as PrEP: ‘women achieved a 75% pregnancy rate with no documented seroconversions or adverse events’. Women were counseled to take tenofovir or FTC/TDF on the morning of the urine-measured luteinizing hormone (LH) peak, repeated 24 h later, and followed by intercourse about 36 h after the LH peak.

These series suggest the feasibility of ARV-based safer conception. While the numbers are too small to draw conclusions about safety, safer conception packages including ART, PrEP, timed conception, STI treatment, and MMC (for F+M− couples) are likely to confer nearly zero risk of HIV transmission when adherence is high. Given the risks, couples currently assume to attempt conception, the risk reduction may be considerable [22[filled square]].


Based on the current data, we recommend the following approach for couples, who choose to attempt conception through intercourse (see Table 2).

Table 2
Recommendations for mutually disclosed serodiscordant couples who choose to attempt conception through intercourse and have completed baseline fertility and preconception evaluation(s)
  • ART: Conception attempts should be delayed until the infected partner is on ART with a suppressed viral load [21[filled square][filled square],68[filled square]], or for at least 6 months [6972]. ART should be continued for life [73,74].
  • PrEP initiation: The uninfected partner should take daily oral FTC/TDF PrEP starting before anticipated peak fertility. Although protection may be conferred within 24 h of the first dose, starting PrEP at the onset of menses will help to ensure maximal protection (based on pharmacokinetics and human behavior) during peak fertility [7577]. Additional antiretroviral agents, formulations, and dosing schedules may be appropriate in the future pending additional data.
  • PrEP discontinuation: Couples should be encouraged to resume condom use and discontinue PrEP once pregnancy is confirmed; as early as 21 days postconception with urine pregnancy testing, or 14 days postconception based on the first day of a missed period [78]. Concerns about fetal ARV exposure for M+F− couples, cost, toxicities, animal data, and the simpler protocol motivate the recommendation to stop PrEP when pregnancy is achieved. Post-exposure prophylaxis for 28-days prevents simian HIV acquisition among macaques [79,80], however there are no human data to suggest whether post-exposure prophylaxis is required on top of PrEP and partner viral load suppression. Animal studies do not support a long period of post-exposure prophylaxis after PrEP [81,82]. Oral PrEP trials administered continuous prophylaxis, but women with pregnancies discontinued PrEP; data regarding this subgroup will inform future practice [83[filled square][filled square]].
    Couples who achieve pregnancy are at particular risk for transmitting and acquiring HIV [8486] and condom use once pregnancy is achieved must be emphasized. For F+M− couples with insurmountable obstacles to condom use, continuing PrEP for the uninfected male through pregnancy should be considered. Given limited PrEP data in pregnant women (although many HIV-infected women take TDF and FTC/TDF with few reported problems [87]), we cannot currently formally recommend PrEP continuation for M+F− couples during pregnancy. However, for many women the risk reduction benefits of PrEP will outweigh the possible toxicities.
  • PrEP without ART: For M+F− couples in which the infected partner does not meet local criteria for or want to take ART, or who are not willing to delay conception attempts, PrEP coupled with timed sex and STI treatment is an optional risk reduction strategy. For F+M− couples, we hesitate to recommend PrEP for the man without ART for the infected woman. In most cases, a woman should start ART for her own health regardless of pregnancy, and treatment may reduce the risk of pregnancy-associated mortality for HIV-infected women [88,89]. In addition, for women with pregnancy, ART initiation is often recommended soon after pregnancy to prevent vertical transmission [72,9092]; more time on ART and viral load suppression at conception are associated with reduced risk of perinatal transmission [93,94]. For women who do not need – or meet local criteria – to initiate ART for their own health and wish to avoid ART during early embryogenesis, periconception PrEP for the uninfected male with ARV initiation for the woman during pregnancy may be reasonable.
  • Non-ARV prevention: ARV use should be combined with sex without condoms limited to peak fertility and STI treatment. For F+M− couples, MMC should be pursued.

No data exist to assess whether PrEP is a necessary adjunct for serodiscordant couples wherein the infected partner is on effective ART, however the highest level of protection is likely achieved by combining ART and PrEP. A public health approach may select one of these strategies: ART for the infected partner provides the highest-level of protection, but uninfected-partner PrEP is an effective risk reduction option when the infected partner is not reliably taking ART. Time-limited, periconception PrEP limits many potential drawbacks to continuous PrEP, including cost, adherence, toxicity, and behavioral risk compensation; additionally, it provides an opportunity to engage high-risk, uninfected individuals in prevention [48,95].

Limitations of antiretrovirals-as-prevention for safer conception

Differential HIV suppression in the genital tract and blood plasma may limit effectiveness of infected-partner ART as a safer conception strategy. Three to forty percentage of men and women with suppressed plasma viral load have detectable virus in the genital tract [96[filled square],97100] and genital viral load correlates (independent of plasma load) with HIV transmission risk [96[filled square]]. Studies of how genital shedding affects transmission, and which anti-retrovirals best suppress replication in genital compartments will further define strategies [76,101104].

Concerns about tenofovir teratogenicity (FDA Class B) may limit deployment of periconception PrEP for women. Trials including systemic or topical tenofovir as PrEP excluded women with plans for pregnancy, although many women in these trials became pregnant [39[filled square][filled square],83[filled square][filled square]] and reports on pregnancy outcomes are expected. The International Antiretroviral Pregnancy Registry reports outcomes for 1219 babies with first trimester exposure to tenofovir: 27 had birth defects, a prevalence of 2.2% (95% confidence interval 1.5, 3.2%), within the range observed in the general population [87] and WHO. and US Perinatal Guidelines recommend tenofovir in regimens initiated during pregnancy [9092]. Fetal safety should be considered in future PrEP development. If topical preparations prove effective and nonspermicidal, these may provide protection with limited systemic effects.

HIV-exposed uninfected children born to women taking ARVs may have worse health outcomes than unexposed infants [105108]. Teasing out the effects of exposure to ARVs versus HIV is ongoing. Guidelines recommend including ARV exposure in the child’s medical history and having a low threshold to evaluate these children for mitochondrial toxicity [92]. Periconception PrEP as we propose results in minimal ARV exposure during embryogenesis.

ART-mediated viral load suppression and PrEP efficacy are highly dependent on adherence [39[filled square][filled square],60[filled square][filled square],61,109111,112[filled square][filled square]]. Stable serodiscordant partners may be motivated to adhere to ARVs for prevention [65[filled square][filled square]] and several studies suggest that individuals may modify risk behavior in order to prevent their child from acquiring HIV [22[filled square],113115]. Stable serodiscordant couples who choose to conceive may be able to adhere to ARV prevention strategies and represent a priority group to consider for application of ARVs-as-prevention.

Additional considerations for serodiscordant couples who attempt conception

Financing of ARVs-as-prevention will depend on additional efficacy and effectiveness data, costs, and recommendations from governmental and international bodies. ARVs-as-prevention will be most cost-effective for high-risk populations with excellent adherence to effective strategies [116[filled square], 117,118]. Oral PrEP for HIV-serodiscordant couples attempting conception is predicted to avert 1–10% of new infections, with a cost of US$2000–8000 per infection prevented [116[filled square]]. The model assumes high risk outside of these interventions and does not account for a decreased risk of perinatal transmission or expected benefits of engaging uninfected partners in prevention.

Periconception risk-reduction interventions that include ARVs will require healthcare worker involvement. Cross-sectional studies show that people living with HIV welcome safer conception advice from providers, but providers are not routinely discussing fertility desires or plans [13,22[filled square],119,120[filled square][filled square],121,122]. With improved prevention opportunities, work to help clinicians increase assessments of fertility plans and provide risk reduction counseling and interventions will be needed.

Preconception counseling for HIV-serodiscordant couples should include couples-based HIV testing, counseling, supported disclosure, and education about serodiscordance [21[filled square][filled square],54]. When couples understand their HIV status and transmission risks, we recommend a discussion of the options for having children. For those who choose to have children, we recommend a baseline fertility assessment to limit HIV exposure among those unlikely to conceive. Additional fertility evaluations should be pursued if initial assessments predict conception challenges or if pregnancy is not achieved after 6 months of conception attempts. We recommend the following baseline preconception evaluation for men and women living with HIV and their partners:

  1. For individuals and couples living with HIV and their partners
    1. Couples-based HIV testing, counseling, supported disclosure.
    2. Education about serodiscordance, HIV transmission risk.
    3. Assess plans for having children.
  2. For those considering reproduction
    1. Education about HIV transmission risks and periconception risk reduction strategies. (Table 1)
    2. Fertility evaluation
      1. Woman’s age, menstrual cycles
      2. Both partners’ fertility history
      3. Semen analysis when possible (especially if male partner infected).
      4. Additional fertility workup dictated by history (e.g. abnormal menses, advanced maternal age).
      5. Full fertility workup (based on local standard) if no pregnancy after 6 months of conception attempts.
  3. For those who choose to attempt conception
    1. Standard of care preconception screening (STI screen, serologies for rubella, hepatitis B virus, cervical cancer screening) and immunizations (Tdap, MMR, HBV as appropriate).
    2. Education re. timing peak fertility.
    3. Referral to MMC (for F+M− couples).
    4. ART: standard evaluation prior to initiation of ART, adherence counseling, supported disclosure to other supports.
    5. PrEP (if indicated) evaluation: serum Cr, HBV, adherence counselling.


Advances in ARV-based prevention dramatically increase safer conception options for HIV-serodiscordant couples. The standard of care in resource-rich settings has become sperm processing and assisted reproduction for M+F− couples, yet costs and limited access make this a difficult option for most. Given discordant genital and plasma viral loads, it is appropriate to recommend sperm processing for M+F− couples, who can access it, but for those who cannot or prefer other options, ARVs-as-prevention are an excellent alternative.

To further develop safer conception options for serodiscordant couples, additional research into effectiveness of ARVs-as-prevention, efficacy of topical PrEP agents, impacts of topical and systemic PrEP on pregnancy and pregnancy outcomes, how providers advise serodiscordant couples about safer conception practices, and how couples consider, negotiate and implement these practices in diverse settings is needed. Safer conception guidelines and policies are needed to facilitate and promote safer conception practices for HIV-serodiscordant couples who choose to conceive.


In order to minimize periconception HIV-transmission among serodiscordant couples, conception attempts should be delayed until the infected partner is on ART. For M+F− couples, ART for the infected partner may be combined with sperm processing or intercourse timed to peak fertility, PrEP for the uninfected partner, and STI treatment. For F+M− couples not willing to carry out non-intercourse insemination, we recommend infected-partner ART, MMC, sex without condoms timed to peak fertility, PrEP for the uninfected partner, and STI treatment. We recommend daily dosing of PrEP starting at menses and continuing until pregnancy is achieved. In cases where the infected partner does not want, meet criteria, or cannot adhere to ART, we recommend PrEP for the uninfected partner. Healthcare workers should be educated about these options to facilitate deployment.


  • Antiretrovirals as HIV prevention can be applied to safer conception for serodiscordant couples to help couples meet reproductive goals while minimizing HIV transmission to uninfected partners.
  • Antiretroviral (ARV)-based risk reduction strategies include delaying conception attempts until the infected partner is on ART, daily oral FTC/tenofovir disoproxilfumarate (TDF) PrEP for the uninfected partner until pregnancy is achieved, sex without condoms limited to peak fertility, and pretreating both partners for sexually transmitted infections (STIs). Medical male circumcision for female-positive couples should also be offered.
  • Adherence to ART and PrEP will be critical to the effectiveness of these interventions. Stable serodiscordant couples attempting to conceive may have particular motivation to adhere to ART and periconception PrEP.


L.T.M. is supported by a K23 award (MH095655). J.A.S. is supported by the William and Flora Hewlett Foundation. We thank Dr. David R. Bangsberg and Dr. Matthew J. Ehrlich for important contributions to the article.


Conflicts of interest

The authors report no conflicts of interest.


Papers of particular interest, published within the annual period of review, have been highlighted as:

[filled square] of special interest

[filled square][filled square] of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 611).

1. Chen JL, Philips KA, Kanouse DE, et al. Fertility desires and intentions of HIV-positive men and women. Fam Plann Perspect. 2001;33:144–152. [PubMed]
2. Ogilvie GS, Palepu A, Remple VP, et al. Fertility intentions of women of reproductive age living with HIV in British Columbia, Canada. AIDS. 2007;21 (Suppl 1):S83–S88. [PubMed]
3. Frodsham LC, Boag F, Barton S, Gilling-Smith C. Human immunodeficiency virus infection and fertility care in the United Kingdom: demand and supply. Fertil Steril. 2006;85:285–289. [PubMed]
4. Heard I, Sitta R, Lert F. Reproductive choice in men and women living with HIV: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA Study) AIDS. 2007;21 (Suppl 1):S77–S82. [PubMed]
5. Panozzo L, Battegay M, Friedl A, Vernazza PL. High risk behaviour and fertility desires among heterosexual HIV-positive patients with a serodiscordant partner–two challenging issues. Swiss Med Wkly. 2003;133:124–127. [PubMed]
6. Beyeza-Kashesya J, Ekstrom AM, Kaharuza F, et al. My partner wants a child: a cross-sectional study of the determinants of the desire for children among mutually disclosed sero-discordant couples receiving care in Uganda. BMC Public Health. 2010;10:247. [PMC free article] [PubMed]
7. Cooper D, Moodley J, Zweigenthal V, et al. Fertility intentions and reproductive healthcare needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services. AIDS Behav. 2009;13 (Suppl 1):38–46. [PubMed]
8. Homsy J, Bunnell R, Moore D, et al. Reproductive intentions and outcomes among women on antiretroviral therapy in rural Uganda: a prospective cohort study. PLoS ONE. 2009;4:e4149. [PMC free article] [PubMed]
9. Myer L, Morroni C, Rebe K. Prevalence and determinants of fertility intentions of HIV-infected women and men receiving antiretroviral therapy in South Africa. AIDS Patient Care STDS. 2007;21:278–285. [PubMed]
10. Nakayiwa S, Abang B, Packel L, et al. Desire for children and pregnancy risk behavior among HIV-infected men and women in Uganda. AIDS Behav. 2006;10 (4 Suppl):S95–S104. [PubMed]
11. Preston-Whyte E. Culture, context and behaviour: anthropological perspectives on fertility in Southern Africa. South Afr J Demogr. 1988;2:13–23. [PubMed]
12. Beyeza-Kashesya J, Kaharuza F, Mirembe F, et al. The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda. African Health Sci. 2009;9:2–12. [PubMed]
13. Cooper D, Harries J, Myer L, et al. ‘Life is still going on’: reproductive intentions among HIV-positive women and men in South Africa. Soc Sci Med. 2007;65:274–283. [PubMed]
14. Dunkle KL, Stephenson R, Karita E, et al. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. Lancet. 2008;371:2183–2191. [PubMed]
15. Guthrie BL, de Bruyn G, Farquhar C. HIV-1-discordant couples in sub-Saharan Africa: explanations and implications for high rates of discordancy. Curr HIV Res. 2007;5:416–429. [PubMed]
16. Eyawo O, de Walque D, Ford N, et al. HIV status in discordant couples in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Infect Dis. 2010;10:770–777. [PubMed]
17. Mantell JE, Smit JA, Stein ZA. The right to choose parenthood among HIV-infected men and women. J Public Health Policy. 2009;30:367–378. [PMC free article] [PubMed]
18. Gruskin S, Ferguson L, O’Malley J. Ensuring sexual and reproductive health for people living with HIV: an overview of key human rights, policy and health systems issues. Reprod Health Matters. 2007;15 (Suppl 29):4–26. [PubMed]
19. London L, Orner PJ, Myer L. ‘Even if you’re positive, you still have rights because you are a person’: human rights and the reproductive choice of HIV-positive persons. Dev World Bioeth. 2008;8:11–22. [PubMed]
20. GNP+, ICW, Young Positives, EngenderHealth, IPPF, and UNAIDS. Advancing the sexual and reproductive health and human rights of people living with HIV: a guidance package. The Global Network of People Living with HIV/AIDS; Amsterdam: 2009.
21[filled square][filled square]. World Health Organization. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples. Geneva: 2012. WHO guidelines for HIV-serodiscordant couples. Includes recommendations for couples based counseling and testing in order to help improve disclosure and understandings of serodiscordance and for infected men and women in serodiscordant partnerships to initiate ART for prevention. [PubMed]
22[filled square]. Matthews LT, Crankshaw T, Giddy J, et al. Reproductive decision-making and periconception practices among HIV-positive men and women attending HIV services in Durban, South Africa. AIDS Behav. 2011 [Epub ahead of print]. This article presents data from semi-structured interviews exploring periconception practices among HIV-infected men and women, who report partners of negative or unknown HIV-status. Themes include that couples knowingly risk HIV-transmission in order to conceive, HIV disclosure is infrequent, and pregnancies are rarely planned. These data emphasize the importance of disseminating risk-reduction strategies and support for their implementation for men and women living with HIV and their partners. [PMC free article] [PubMed]
23. Harris C, Small CB, Klein RS, et al. Immunodeficiency in female sexual partners of men with the acquired immunodeficiency syndrome. N Engl J Med. 1983;308:1181–1184. [PubMed]
24. Piot P, Quinn TC, Taelman H, et al. Acquired immunodeficiency syndrome in a heterosexual population in Zaire. Lancet. 1984;2:65–69. [PubMed]
25. Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005;2:e298. [PubMed]
26. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007;369:643–656. [PubMed]
27. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007;369:657–666. [PubMed]
28. Eke AC, Oragwu C. Sperm washing to prevent HIV transmission from HIV-infected men but allowing conception in sero-discordant couples. Cochrane Database Syst Rev. 2011;(1):CD008498. [PubMed]
29. Bujan L, Hollander L, Coudert M, et al. Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network. AIDS. 2007;21:1909–1914. [PubMed]
30. Savasi V, Ferrazzi E, Lanzani C, et al. Safety of sperm washing and ART outcome in 741 HIV-1-serodiscordant couples. Hum Reprod. 2007;22:772–777. [PubMed]
31. Vitorino RL, Grinsztejn BG, de Andrade CA, et al. Systematic review of the effectiveness and safety of assisted reproduction techniques in couples serodiscordant for human immunodeficiency virus where the man is positive. Fertil Steril. 2011;95:1684–1690. [PubMed]
32. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. European Study Group on Heterosexual Transmission of HIV. N Engl J Med. 1994;331:341–346. [PubMed]
33. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002;(1):CD003255. [PubMed]
34[filled square][filled square]. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. N Engl J Med. 2011;365:493–505. HPTN 052 was a randomized, controlled trial carried out among 1763 mutually disclosed HIV-serodiscordant couples in which the antiretroviral-naive infected partner was randomized to ART at enrollment (CD4 cell count 350–550 cells/μl) or upon decline in CD4 to 250 or fewer cells per μl or onset of AIDS-defining illness. Early therapy was associated with a 96% reduction in the risk of transmission to the uninfected partner. We believe these data support the application of ART for the infected partner to reduce periconception HIV sexual transmission risk. [PMC free article] [PubMed]
35. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010;375:2092–2098. [PMC free article] [PubMed]
36. Attia S, Egger M, Muller M, et al. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS. 2009;23:1397–1404. [PubMed]
37[filled square][filled square]. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV-1 prevention in heterosexual men and women. NEJM. 2012;367:399–410. The Partners PrEP trial enrolled 4758 couples in stable, serodiscordant partnerships. Uninfected partners randomized to oral, daily TDF or FTC/TDF had a 67 or 75% reduced risk of HIV acquisition compared with couples on placebo. Efficacy was higher among those with detectable drug levels (86% risk reduction for TDF and 90% risk reduction for TDF/FTC.) Adherence in this study was high with 97% of dispensed study tablets taken. Efficacy was not different according to sex. [PMC free article] [PubMed]
38[filled square][filled square]. Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. NEJM. 2012;367:423–434. This RCT reports on 1219 heterosexual men and women randomized to daily oral PrEP with FTC/TDF versus placebo. The FTC/TDF group had a 62% reduction in HIV acquisition risk. [PubMed]
39[filled square][filled square]. Van Damme L, Corneli A, Ahmed K, et al. Preexposure prophylaxis for HIV infection among African women. NEJM. 2012;367:411–422. Among 2120 African women randomized to daily oral FTC/TDF versus placebo, HIV incidence was 4.7/100 person years in the FTC/TDF arm and 5.0/100 person years in the placebo arm for an estimated hazard ratio of 0.94 (0.59–1.52, P =.81). Drug was detectable in fewer than 40% of infected cases and uninfected controls, leading to speculation that futility may have resulted from poor adherence. [PMC free article] [PubMed]
40. Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet. 1995;346:530–536. [PubMed]
41. Wawer MJ, Gray RH, Sewankambo NK, et al. A randomized, community trial of intensive sexually transmitted disease control for AIDS prevention, Rakai, Uganda. AIDS. 1998;12:1211–1225. [PubMed]
42. Philips B, Ball C, Sackett D, Badenoch D, Straus S, Haynes B, Dawes M. [Accessed on 30 May 2012];Oxford Centre for Evidence-based Medicine – Levels of Evidence. 2009 Mar;
43. Mmeje O, Cohen C, Cohan D. Evaluating safer conception options for HIV-infected female/HIV-uninfected male serodiscordant couples: a closer look at vaginal insemination. Infect Dis Obstet Gynecol. 2012;206:e21. [PMC free article] [PubMed]
44. Semprini AE, Levi-Setti P, Bozzo M, et al. Insemination of HIV-negative women with processed semen of HIV-positive partners. Lancet. 1992;340:1317–1319. [PubMed]
45. Politch JA, Anderson DJ. Use of assisted reproductive technology to prevent the transmission of HIV-1 in HIV-discordant couples desiring children. Immunol Allergy Clin North America. 2002;22:663–679.
46. Sauer MV, Wang JG, Douglas NC, et al. Providing fertility care to men seropositive for human immunodeficiency virus: reviewing 10 years of experience and 420 consecutive cycles of in vitro fertilization and intracytoplasmic sperm injection. Fertil Steril. 2009;91:2455–2460. [PubMed]
47. Nicopoullos JD, Almeida P, Vourliotis M, Gilling-Smith C. A decade of the United Kingdom sperm-washing program: untangling the transatlantic divide. Fertil Steril. 2010;94:2458–2461. [PubMed]
48. Lampe MA, Smith DK, Anderson GJ, et al. Achieving safe conception in HIV-discordant couples: the potential role of oral preexposure prophylaxis (PrEP) in the United States. Am J Obstet Gynecol. 2011;204:488.e1–8. [PubMed]
49. Barreiro P, del Romero J, Leal M, et al. Natural pregnancies in HIV-serodiscordant couples receiving successful antiretroviral therapy. J Acquir Immune Defic Syndr. 2006;43:324–326. [PubMed]
50. Mandelbrot L, Heard I, Henrion-Geant E, Henrion R. Natural conception in HIV-negative women with HIV-infected partners. Lancet. 1997;349:850–851. [PubMed]
51. Matthews L, Mukherjee J. Strategies for harm reduction among HIV-affected couples who want to conceive. AIDS and Behavior. 2009;13 (Suppl 1):S5–S11. [PubMed]
52[filled square]. Crankshaw T, Matthews LT, Giddy J, et al. A conceptual framework for periconception HIV transmission risk reduction among HIV serodiscordant couples. Reprod Health Matters. 2012 (in press). This article presents a conceptual framework for considering structural, individual, and dyadic domains that impact how couples and individuals implement behavioral change to minimize periconception HIV transmission. [PMC free article] [PubMed]
53. Jewkes R, Morrell R. Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. J Int AIDS Soc. 2010;13:6. [PMC free article] [PubMed]
54. Kelley AL, Karita E, Sullivan PS, et al. Knowledge and perceptions of couples’ voluntary counseling and testing in urban Rwanda and Zambia: a cross-sectional household survey. PLoS ONE. 2011;6:e19573. [PMC free article] [PubMed]
55. UNAIDS. Fact Sheet: Women, girls, gender equality, and HIV. UNAIDS; 2010. [Accessed 30 May 2012].
56. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med. 2000;342:921–929. [PubMed]
57. Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis. 2005;191:1403–1409. [PubMed]
58. Das M, Chu PL, Santos GM, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5:e11068. [PMC free article] [PubMed]
59. Montaner JS, Lima VD, Barrios R, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010;376:532–539. [PMC free article] [PubMed]
60[filled square][filled square]. Abdool Karim Q, Abdool Karim SS, Frohlich JA, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 2010;329:1168–1174. CAPRISA 004 was the first successful efficacy trial of topical PrEP. Among 889 at-risk women in South Africa, application of 1% tenfovir vaginal gel versus placebo up to 12 h before and 12 h after sex without more than 2-doses in 24 h conferred a 39% reduction in the risk of HIV acquisition. High adherers (gel applied twice with at least 80% of sex acts) had a 54% reduction in risk of acquisition. [PMC free article] [PubMed]
61. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587–2599. [PMC free article] [PubMed]
62. Microbicide Trials Network. [Accessed on 28 September 2011];MTN statement on decision to discontinue use of oral tenofovir tablets in VOICE, a major HIV prevention study in women. 2011
63. Microbicide Trials Network. [Accessed on 25 November 2011];MTN statement on decision to discontinue use of Tenofovir gel in VOICE, a major HIV prevention study in women. 2011
64. van der Straten A, Van Damme L, Haberer JE, Bangsberg DR. Unraveling the divergent results of preexposure prophylaxis trials for HIV prevention. AIDS. 2012;26:F13–F19. [PubMed]
65[filled square][filled square]. Ware NC, Wyatt MA, Haberer JE, et al. What’s love got to do with it? Explaining adherence to oral antiretroviral preexposure prophylaxis for HIV-serodiscordant couples. J Acquir Immune Defic Syndr. 2012;59:463–468. This article presents data from qualitative interviews carried out with Partners PrEP trial participants – 45 uninfected participants and 15 partners. Inductive grounded theory analysis suggested that a desire to reduce HIV transmission risk and thus preserve a partnership may motivate adherence to PrEP. This qualitative work will inform future behavioral science to understand adherence to prevention strategies for serodiscordant couples. [PMC free article] [PubMed]
66. [Accessed on 16 July 2012];Press release: FDA approves first drug for reducing the risk of sexually acquired HIV infection. 2012
67[filled square][filled square]. Vernazza PL, Graf I, Sonnenberg-Schwan U, et al. Preexposure prophylaxis and timed intercourse for HIV-discordant couples willing to conceive a child. AIDS. 2011;25:2005–2008. Pietro Venazza and colleagues offered a package of ARV-based safer conception strategies to M+F−serodiscordant couples as an alternative to sperm processing and assisted reproduction. This series reports on 46 serodiscordant couples who chose ART for the infected partner, peri-ovulatory PrEP for the uninfected partner, plus sex timed to peak fertility for conception. There were no seroconversions or adverse events and the pregnancy rate was about 75%. This series suggests the feasibility and acceptability of ARV-based safer conception strategies. (numbers confirmed with Dr Vernazza via personal communication) [PubMed]
68[filled square]. Bekker LG, Black V, Myer L, et al. Guideline on safer conception in fertile HIV-infected individuals and couples. Southern African J HIV Med. 2011;12:31–44. Comprehensive recommendations for safer conception strategies for HIV-positive men and women and their partners offered by a consensus committee for the Southern African HIV Clinicians Society, with particular considerations for more developed and less developed settings.
69. Mocroft A, Miller V, Chiesi A, et al. Virological failure among patients on HAART from across Europe: results from the EuroSIDA study. Antivir Ther. 2000;5:107–112. [PubMed]
70. Cescon AM, Cooper C, Chan K, et al. Factors associated with virological suppression among HIV-positive individuals on highly active antiretroviral therapy in a multisite Canadian cohort. HIV Med. 2011;12:352–360. [PubMed]
71. Matthews GV, Sabin CA, Mandalia S, et al. Virological suppression at 6 months is related to choice of initial regimen in antiretroviral-naive patients: a cohort study. AIDS. 2002;16:53–61. [PubMed]
72. Egger M, May M, Chene G, et al. Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. Lancet. 2002;360:119–129. [PubMed]
73. World Health Organization. Recommendations for a public health approach: 2010 revision. W.H.O; Geneva: 2010. Antiretroviral therapy for HIV infection in adults and adolescents. [PubMed]
74. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Department of Health and Human Services; 2012. [Accessed on 1 May 2012].
75. Dumond JB, Yeh RF, Patterson KB, et al. Antiretroviral drug exposure in the female genital tract: implications for oral pre and postexposure prophylaxis. AIDS. 2007;21:1899–1907. [PMC free article] [PubMed]
76. Patterson KB, Prince HA, Kraft E, et al. Penetration of tenofovir and emtricitabine in mucosal tissues: implications for prevention of HIV-1 transmission. Sci Transl Med. 2011;3:112re4. [PMC free article] [PubMed]
77. Mutua G, Sanders E, Mugo P, et al. Safety and adherence to intermittent preexposure prophylaxis (PrEP) for HIV-1 in African men who have sex with men and female sex workers. PLoS ONE. 2012;7:e33103. [PMC free article] [PubMed]
78. Wilcox AJ, Baird DD, Dunson D, et al. Natural limits of pregnancy testing in relation to the expected menstrual period. JAMA. 2001;286:1759–1761. [PubMed]
79. Tsai CC, Emau P, Follis KE, et al. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. J Virol. 1998;72:4265–4273. [PMC free article] [PubMed]
80. Tsai CC, Follis KE, Sabo A, et al. Prevention of SIV infection in macaques by (R)-9-(2-phosphonylmethoxypropyl)adenine. Science. 1995;270:1197–1199. [PubMed]
81. Cong ME, Youngpairoj AS, Zheng Q, et al. Protection against rectal transmission of an emtricitabine-resistant simian/human immunodeficiency virus SHIV162p3M184V mutant by intermittent prophylaxis with Truvada. J Virol. 2011;85:7933–7936. [PMC free article] [PubMed]
82. Garcia-Lerma JG, Otten RA, Qari SH, et al. Prevention of rectal SHIV transmission in macaques by daily or intermittent prophylaxis with emtricitabine and tenofovir. PLoS Med. 2008;5:e28. [PubMed]
83[filled square][filled square]. Mugo N, Celum C, Donnell D, et al. CROI. Seattle: 2012. Pregnancy Incidence and Birth Out comes among in a Clinical Trial of PrEP: Uganda and Kenya; p. 1060. Among 1785 HIV-uninfected women in the Partners PrEP trial, there were 288 pregnancies for an incidence of 10.3/100 woman-years. Pregnancy rates were similar for women receiving PrEP vs. placebo. Although data on fertility desire were not collected, high pregnancy rates among women with known HIV-infected partners emphasize the importance of risk reduction for HIV-serodiscordant couples who may choose to conceive.
84. Mugo NR, Heffron R, Donnell D, et al. Increased risk of HIV-1 transmission in pregnancy: a prospective study among African HIV-1-serodiscordant couples. AIDS. 2011;25:1887–1895. [PMC free article] [PubMed]
85. Kharsany AB, Hancock N, Frohlich JA, et al. Screening for ‘window-period’ acute HIV infection among pregnant women in rural South Africa. HIV Med. 2010;11:661–665. [PMC free article] [PubMed]
86. Moodley D, Esterhuizen TM, Pather T, et al. High HIV incidence during pregnancy: compelling reason for repeat HIV testing. AIDS. 2009;23:1255–1259. [PubMed]
87. The Antiretroviral Pregnancy Registry. [Accessed on 15 May 2012];
88. Black V, Brooke S, Chersich MF. Effect of human immunodeficiency virus treatment on maternal mortality at a tertiary center in South Africa: a 5-year audit. Obstet Gynecol. 2009;114 (2 Pt 1):292–299. [PubMed]
89. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609–1623. [PubMed]
90. WHO. Executive summary. Geneva: 2012. Programmatic Update: Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants.
91. WHO. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Recommendations for a public health approach. WHO; Geneva: 2010. [PubMed]
92. Department of Health and Human Services; 2011. [Accessed on 1 May 2012]. Panel on treatment of HIV-infected pregnant women and prevention of perinatal transmission, Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States; pp. 1–207.
93. Tubiana R, Le Chenadec J, Rouzioux C, et al. Factors associated with mother-to-child transmission of HIV-1 despite a maternal viral load <500 copies/ml at delivery: a case–control study nested in the French perinatal cohort (EPF-ANRS CO1) Clin Infect Dis. 2010;50:585–596. [PubMed]
94. Read PJ, Mandalia S, Khan P, et al. When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery? AIDS. 2012;26:1095–1103. [PubMed]
95. Matthews LT, Baeten JM, Celum C, Bangsberg DR. Periconception preexposure prophylaxis to prevent HIV transmission: benefits, risks, and challenges to implementation. AIDS. 2010;24:1975–1982. [PMC free article] [PubMed]
96[filled square]. Baeten JM, Kahle E, Lingappa JR, et al. Genital HIV-1 RNA predicts risk of heterosexual HIV-1 transmission. Sci Transl Med. 2011;3:77ra29. Genital HIV-1 RNA samples from 3408 serodiscordant couples enrolled in the Partners in Prevention Trial (RCT to evaluate effect of HSV-2 treatment on HIV transmission) demonstrated a low correlation between genital HIV-1 RNA concentrations and plasma HIV RNA (Spearman’s correlation 0.56 among women, 0.55 among men). There was a 1.67 increased hazards of transmission per log10copies/swab increase in endocervical RNA and a 1.68 per log10copies/mL increase in semen RNA in adjusted models (including adjustment for plasma viral load) [PMC free article] [PubMed]
97. Marcelin AG, Tubiana R, Lambert-Niclot S, et al. Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma. AIDS. 2008;22:1677–1679. [PubMed]
98. Lambert-Niclot S, Tubiana R, Beaudoux C, et al. Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma on a 2002–2011 survey. AIDS. 2012;26:971–975. [PubMed]
99. Cu-Uvin S, Caliendo AM. Genital tract HIV-1 RNA shedding among women with below detectable plasma viral load. AIDS. 2011;25:880–881. [PubMed]
100. Launay O, Tod M, Tschope I, et al. Residual HIV-1 RNA and HIV-1 DNA production in the genital tract reservoir of women treated with HAART: the prospective ANRS EP24 GYNODYN study. Antivir Ther. 2011;16:843–852. [PubMed]
101. Lambert-Niclot S, Peytavin G, Duvivier C, et al. Low frequency of intermittent HIV-1 semen excretion in patients treated with darunavir-ritonavir at 600/100 milligrams twice a day plus two nucleoside reverse transcriptase inhibitors or monotherapy. Antimicrob Agents Chemother. 2010;54:4910–4913. [PMC free article] [PubMed]
102. Karim SS, Kashuba AD, Werner L, Karim QA. Drug concentrations after topical and oral antiretroviral preexposure prophylaxis: implications for HIV prevention in women. Lancet. 2011;378:279–281. [PMC free article] [PubMed]
103. Brown KC, Patterson KB, Malone SA, et al. Single and multiple dose pharmacokinetics of maraviroc in saliva, semen, and rectal tissue of healthy HIV-negative men. J Infect Dis. 2011;203:1484–1490. [PMC free article] [PubMed]
104. Cohen MS, Muessig KE, Smith MK, et al. Antiviral agents and HIV prevention: controversies, conflicts and consensus. AIDS. 2012;26:1585–1598. [PMC free article] [PubMed]
105. Nielsen-Saines K, Komarow L, Cu-Uvin S, et al. Infant outcomes after maternal antiretroviral exposure in resource-limited settings. Pediatrics. 2012;129:e1525–e1532. [PMC free article] [PubMed]
106. Culnane M, Fowler M, Lee SS, et al. Lack of long-term effects of in utero exposure to zidovudine among uninfected children born to HIV-infected women. Pediatric AIDS Clinical Trials Group Protocol 219/076 Teams. JAMA. 1999;281:151–157. [PubMed]
107. Barret B, Tardieu M, Rustin P, et al. Persistent mitochondrial dysfunction in HIV-1-exposed but uninfected infants: clinical screening in a large prospective cohort. AIDS. 2003;17:1769–1785. [PubMed]
108. Blanche S, Tardieu M, Rustin P, et al. Persistent mitochondrial dysfunction and perinatal exposure to antiretroviral nucleoside analogues. Lancet. 1999;354:1084–1089. [PubMed]
109. Howard AA, Arnsten JH, Lo Y, et al. A prospective study of adherence and viral load in a large multicenter cohort of HIV-infected women. AIDS. 2002;16:2175–2182. [PubMed]
110. Bangsberg DR, Hecht FM, Charlebois ED, et al. Adherence to protease inhibitors, HIV-1 viral load, and development of drug resistance in an indigent population. AIDS. 2000;14:357–366. [PubMed]
111. Lima VD, Harrigan R, Bangsberg DR, et al. The combined effect of modern highly active antiretroviral therapy regimens and adherence on mortality over time. J Acquir Immune Defic Syndr. 2009;50:529–536. [PMC free article] [PubMed]
112[filled square][filled square]. Donnell D, Baeten JM, Hendrix C, et al. CROI. Seattle: 2012. Tenofovir disoproxil fumarate drug_levels indicate PrEP use is strongly correlated with HIV-1 protective effects: Kenya and Uganda. (abstract no. 30). In this secondary analysis of the Partners PrEP trial, TDF drug levels were compared between participants who acquired HIV (17 from TDF arm, 12 from FTC/TDF arm) and randomly selected participants who did not acquire HIV. Thirty-five percent of those assigned to TDF and 25% of those assigned to FTC/TDF had detectable plasma TDF at seroconversion. Eighty-three percent of samples from uninfected controls in the TDF arm and 81% of controls from the FTC/TDF arm had detectable TDF. Detectable TDF was thus associated with an 86% reduction in HIV acquisition risk in the TDF arm and with a 90% reduction in risk for the FTC/TDF arm.
113. Mindry D, Maman S, Chirowodza A, et al. Looking to the future: South African men and women negotiating HIV risk and relationship intimacy. Cult Health Sex. 2011;13:589–602. [PMC free article] [PubMed]
114. Bardeguez AD, Lindsey JC, Shannon M, et al. Adherence to antiretrovirals among US women during and after pregnancy. J Acquir Immune Defic Syndr. 2008;48:408–417. [PMC free article] [PubMed]
115. Sha BE, Tierney C, Cohn SE, et al. Postpartum viral load rebound in HIV-1-infected women treated with highly active antiretroviral therapy: AIDS Clinical Trials Group Protocol A5150. HIV Clin Trials. 2011;12:9–23. [PMC free article] [PubMed]
116[filled square]. Hallett TB, Baeten JM, Heffron R, et al. Optimal uses of antiretrovirals for prevention in HIV-1 serodiscordant heterosexual couples in South Africa: a modelling study. PLoS Med. 2011;8:e1001123. This modeling study examines the cost-effectiveness of potential prevention strategies for serodiscordant couples in South Africa. Modeled scenarios include PrEP from time of serodiscordance diagnosis, PrEP only up until ART for the positive partner, PrEP up until 1 year after ART for the positive partner, and PrEP for serodiscordant couples who choose to conceive. [PMC free article] [PubMed]
117. Walensky RP, Park JE, Wood R, et al. The cost-effectiveness of preexposure prophylaxis for HIV infection in South African women. Clin Infect Dis. 2012;54:1504–1513. [PMC free article] [PubMed]
118. Granich R, Kahn JG, Bennett R, et al. Expanding ART for treatment and prevention of HIV in South Africa: estimated cost and cost-effectiveness 2011–2050. PLoS ONE. 2012;7:e30216. [PMC free article] [PubMed]
119. Schwartz SR, Mehta SH, Taha TE, et al. High pregnancy intentions and missed opportunities for patient-provider communication about fertility in a south African cohort of HIV-positive women on antiretroviral therapy. AIDS Behav. 2012;16:69–78. [PubMed]
120[filled square][filled square]. Finocchario-Kessler S, Dariotis JK, Sweat MD, et al. Do HIV-infected women want to discuss reproductive plans with providers, and are those conversations occurring? AIDS Patient Care STDS. 2010;24:317–323. Survey data from 181 HIV-infected women receiving HIV clinical care in two U.S. urban clinics reveal that 31% had ever had a personal conversation with a provider about childbearing plans. The fact that 59% of the women wanted to have a child in the future speaks to the unmet need for reproductive counseling for women living with HIV. [PMC free article] [PubMed]
121. Gogna ML, Pecheny MM, Ibarlucia I, et al. The reproductive needs and rights of people living with HIV in Argentina: health service users’ and providers’ perspectives. Soc Sci Med. 2009;69:813–820. [PubMed]
122. Harries J, Cooper D, Myer L, et al. Policy maker and healthcare provider perspectives on reproductive decision-making amongst HIV-infected individuals in South Africa. BMC Public Health. 2007;7:282. [PMC free article] [PubMed]