It's good news for HIV-affected couples and those who treat them: The U.S. Centers for Disease Control and Prevention (CDC) is, at long last, truly up-to-date on its HIV-affected conception guidance.
Unlike the previous conception guidance issued in the CDC's Morbidity and Mortality Weekly Report (MMWR) at the beginning of June, the new guidance issued today ("Effects of Antiretroviral Therapy to Prevent HIV Transmission to Women in Couples Attempting Conception When the Man Has HIV Infection -- United States, 2017") quotes data from HIV trials showing that treatment alone can prevent HIV transmission when couples with mixed HIV status desire to have a baby.
It then lists other methods for safely conceiving a child when a man is living with HIV and a woman is not, including pre-exposure prophylaxis (PrEP), limiting condomless sex to ovulation, and sperm washing with technological support. Importantly, unlike the June guidance, it does not imply that physicians must counsel couples to use all methods together to prevent transmission.
The updated guidance was published Aug. 17, as was an additional erratum note linked to the earlier guidance.
The update and erratum are the result of intensive work between community advocates and the CDC.
For Shannon Weber, M.S.W., director of HIVE, the University of California San Francisco's center for HIV-related sexual health and pregnancy, the new guidance is the best-case scenario after the CDC's distressing guidance in June.
"As devastating as it was to read the June 2nd MMWR, I am thrilled to see the CDC response to community feedback," she told TheBodyPRO.com. "This new erratum on safer conception is scientifically sound, includes people-first language and presents options with an emphasis on individual choice. Well done, CDC!"
Righting a Wrong and Stumbling
Jennifer F. Kawwass, M.D., has spent her career trying to increase couples' access to fertility services. So, when she helped draft the language that would eventually appear in the CDC's MMWR, she had one goal: to updated the long-outdated guidance from the CDC that warned against offering assisted reproductive services to HIV-affected couples in which the man was living with HIV.
"Historically, discordant couples have had limited access to fertility services, likely partly due to the outdated 1990 CDC guidance," she told TheBodyPRO.com. "The hope is that this [update] will improve access to fertility services when needed."
The June 2 guidance stated, "Recent data regarding the safety of semen processing suggest that such processing is a viable option for HIV discordant couples attempting conception."
This language replaced 1990 guidance, which stated, "There is no evidence that any procedure can reliably eliminate HIV from semen," and "CDC recommends against insemination with semen from HIV-infected men."
In the process, though, the updated, June guidance stated that, in order to conceive safely, providers should inform couples of the following two options: condomless sex during ovulation when a man has an undetectable viral load (treatment as prevention or TasP) and while the woman is on the HIV prevention medication Truvada (tenofovir/emtricitabine) as PrEP. Or, the guidance stated, couples could have the man's sperm "washed" via centrifuge to remove the potentially HIV-carrying seminal fluid from sperm. Then that sperm could be used to help the couple conceive a child via intrauterine insemination (IUI) or in vitro fertilization (IVF). Risk could be reduced further by TasP and PrEP.
Backlash and a Correction
But multiple studies, including HPTN 052, PARTNER and, most recently, the Opposites Attract study, show that TasP alone can prevent HIV transmission. Anthony Fauci, M.D., director of the U.S. National Institute of Allergy and Infectious Diseases told TheBody.com last year that the science is so convincing that condoms for people with undetectable viral loads are now optional. Likewise, data from the Partners PrEP and iPrEx studies show that PrEP alone can prevent HIV transmission.
"The lack of information and clear guidance on TasP and PrEP as stand-alone options --whether for HIV-positive female/HIV-negative male or HIV-positive male/HIV-negative female couples -- is disappointing," Weber told TheBodyPRO.com in June.
But, when I spoke to Kawwass, she said that the guidance was intended to state that each prevention technique could reduce risk. The language was simply unclear.
The guidance was meant to say that all risk-reduction techniques, including TasP, PrEP and sperm washing, "are and/or," she said.
But that isn't what the guidance actually said.
Community Advocacy and a Correction
Community advocates pushed hard to correct the data. They didn't want erroneous guidance on TasP and PrEP to be in place for 27 years, the way the sperm-washing guidance was. Weber said that, with the CDC's sperm-washing guidance in place, "U.S.-assisted reproductive technology services for HIV-affected couples has lagged embarrassingly behind global north countries for nearly two decades."
The CDC's "seal of approval" in the form of an MMWR guidance forms the basis of the standard of care, which many HIV-affected couples say has frustrated or outright blocked their efforts to have children. The hope is that now, with science-based language and state-of-the-art science reflected in the most current, August guidance, couples will have the opportunity to have the families they desire.
The new guidance lays out options that start with TasP and then include PrEP, sperm washing, and in utero insemination or in vitro fertilization. "The extent to which any of these interventions further decreases HIV risk below that associated with viral suppression and an undetectable viral load is unknown," the guidance states.
But, the guidance doesn't just stop there. It urges providers to talk about the fertility desires of HIV-affected couples -- something very new.
"It is important that health care providers regularly assess mixed HIV-status couples' plans for conception," the guidance states. "Considering factors such as risk tolerance, personal health, costs, and access to health care services, providers can help couples make the best decision for their personal circumstances."
This brings the CDC's guidance in line with the safer-conception consensus statement developed by an international group of providers and advocates beginning in 2015. Recently, at IAS 2017, those providers gathered again to further address the consensus and to discuss how to fold undetectable = untransmittable language into it.
Now, the hope is that U.S. providers will not only talk to their patients about safer conception but also provide them with evidence-based approaches that can ease their path toward building the families they desire.
"The CDC seal of approval is now in line with current science and supports a patient-centered approach," Weber told TheBodyPRO.com, "which brings the U.S. in line with other country guidelines and expands accessible safer-conception options for thousands of Americans living and loving with HIV."
Heather Boerner is a health care journalist based in San Francisco and author of Positively Negative: Love, Pregnancy and Science's Surprising Victory Over HIV.