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Washington Post
Susan and Dan Hartmann of Odenton, Md., chose to conceive their daughter, Ryan, the old-fashioned way – even though Dan is HIV-positive.

Mixed-status HIV couples go old-style

Pill cuts risk of infection being spread

When Susan Hartmann got married, she and her husband knew they had to be careful. Given that she’s HIV-negative and he’s HIV-positive, they had to be vigilant about protected sex. But later, they decided they wanted to start a family.

After hearing about high-tech assisted reproduction techniques that could help them conceive safely, they sought advice from the perinatal HIV clinic at the University of California at San Francisco. But the doctors presented an option they hadn’t considered: They could do it the old-fashioned way, by having unprotected sex.

Hartmann was floored by the suggestion. “It was counter to decades of public health messaging,” she said.

She and her husband, Dan, looked at the research. Numerous studies supported the idea that her risk of infection was extremely low because his viral load was undetectable, and they would be having unprotected sex only a few times, when she was ovulating.

The couple decided to go for it, and the happy result was a little girl they named Ryan. Both mother and daughter are HIV-negative.

More than 1.1 million Americans – about three-fourths of them men – are infected with HIV, and as they are living longer, healthier lives thanks to advances in anti-retroviral therapy, a growing number have expressed the desire to start a family.

Couples in which one or both partners are HIV-positive have been using adoption, surrogacy or donor eggs or sperm for years, but those options are expensive. Today, some doctors are endorsing intercourse without a condom as another option. It allows couples to have biological children, and it’s free.

Medical professionals are backed by a new understanding about the mechanisms of HIV transmission and the development of a fantastically effective once-a-day pill taken by the HIV-negative partner that can reduce the risk of infection.

And a baby born to an HIV-positive mother, regardless of the father’s status, now has a less than 1 percent chance of getting the virus, with proper treatment.

“We have gone from a story of risk reduction to one of possibility,” said Shannon Weber, coordinator for the Bay Area Perinatal AIDS Center in San Francisco, which in 2012 started a program to help HIV-positive men with HIV-negative women – the most complicated situation to deal with from a medical standpoint – have children.

“We have done such a disservice to them over the years,” Weber said. “They have had very little information about safe conception, and for many of them, this is the first time they were asked whether or not they wanted to have a family.”

Erika Aaron, an assistant professor at Drexel University’s College of Medicine, has helped five HIV-negative women with HIV-positive partners get pregnant through intercourse while on anti-retrovirals over the past year and a half. None have become infected with HIV.

She said that when she started talking about this option, “it was hard to get the words out of my mouth” because she had been telling people the opposite for so many years.

But, Aaron said, “now that we know ways we can minimize transmission by ways other than using condoms, it’s important that we let them know this is an option.”

The view isn’t universally accepted. Some primary-care physicians say they are uncomfortable with the approach because the risk of transmission, however small, still exists, and it is their responsibility to do no harm.

Michael Weinstein, president of the Los-Angeles based AIDS Healthcare Foundation, said HIV viral loads fluctuate and that even the most well-intentioned would-be mothers and fathers could forget to take their medication. He said that if there happens to be a spike in a man’s viral load while a couple is trying to conceive, the risk to the woman would increase dramatically.

“People are going to make whatever decision about risk with their doctors,” Weinstein said.

“But as a public health person, I cannot advocate this.”