The quality of evidence (I-III) and classification of recommendations (A-L) are defined at the end of the "Major Recommendations."
Human immunodeficiency virus (HIV)-positive people who are considering pregnancy should be counselled on the following issues so they can make an informed decision.
Ensuring a Healthy Mother, Child, and Family
- Reproductive health counselling, including contraception and pregnancy planning, should be offered to all reproductive-aged HIV-positive individuals soon after HIV diagnosis and on an ongoing basis. (II-3A)
- Men and women should be counselled on all relevant aspects of pregnancy planning, such as maintaining a healthy diet and lifestyle, the risk of genetic disease occurrence, and integrated prenatal screening, as outlined in current Canadian practice guidelines irrespective of their known HIV status. (III-A)
- Women with no risk factors should start taking folic acid (in the form of vitamin supplements) 1 mg a day for 3 months before becoming pregnant and for at least the first 3 months of their pregnancy. (II-3A)
- Women should be encouraged to give up smoking, drinking alcohol, and using recreational drugs, and should be referred for support if required. (III-A)
- Both prospective parents should be tested for other sexually transmitted infections, even if they have conceived in the past and have no symptoms of infection. (III-A)
Psychosocial/Mental Health Issues Related to HIV Pregnancy Planning and Fertility
All individuals or couples planning pregnancy are potentially susceptible to psychosocial and mental health problems. An additional burden may be placed on the HIV-positive individual or couple because of stigma associated with the condition and the risks of HIV transmission.
- Counselling should be performed by a knowledgeable health care professional or trained peer counsellor in a supportive, non-judgemental manner that takes into account sexual diversity and ethnocultural or religious beliefs and practices. (III-A)
- Counselling should include a discussion of the potential risk for both horizontal (between partners) and vertical (from mother to child) transmission and how that might affect the mental health of one or both parents. (III-A)
- HIV-positive people who intend to conceive should be made aware of the potential stigma and discrimination they may face from others who are less informed about how HIV is transmitted, horizontally and vertically. In addition, HIV-positive women who are not breastfeeding should be made aware that they may face disapproval from people who are not aware of their HIV status. (II-3A)
- Further counselling may be suggested to help couples and individuals cope more effectively with fear, stigma, and other psychosocial issues, such as postpartum depression. (II-3A)
Legal and Ethical Issues
- All HIV-positive individuals should be counselled on the possible legal ramifications of non-disclosure of their HIV status to their sexual partner(s). (III-A)
- HIV-positive women who are considering pregnancy should be counselled on the possibility of legal action if they do not permit antiretroviral therapy to be given to their baby after birth. (III-B)
- Ethical considerations, including those related to the health status of HIV-positive individuals or couples, should be discussed during pre-conception counselling. (III-B)
Antiretroviral and Other Drugs in Pregnancy Planning
- Clinicians should review all medications that HIV-positive men and women may be using, including antidepressants, pain medications, over-the-counter medications, and hepatitis treatment, to ensure that they are safe during conception and pregnancy. (II-3A)
- All HIV-positive men and women who require combination antiretroviral therapy for their own health during the preconception period should be advised to continue their current regimens, but women should not take any drugs that are potentially teratogenic or considered toxic in pregnancy, substituting other drugs when necessary or possible. The most efficacious regimen that is safe in pregnancy should be selected. (II-3A)
- HIV-positive women who do not require combination antiretroviral therapy for their own health need to consider starting treatment before becoming pregnant or no later than late in the first trimester of pregnancy. The most efficacious regimen that is safe in pregnancy should be selected. (II-3A)
- HIV-positive men and women who require treatment should be encouraged to initiate combination antiretroviral therapy during the pre-conception period to reduce HIV plasma viral load, which can reduce the risk of HIV transmission to their HIV-negative partner or reduce the risk of superinfection of their HIV-positive partner. (II-3B)
- All decisions about the use of combination antiretroviral therapy and other drugs during pregnancy should be made in consultation with experts such as HIV specialists and pharmacists. (III-A)
Scenario-Based Recommendations for the Prevention of Horizontal HIV Transmission
The recommended option may not always be the most practical or preferred option for the patient, given availability of services, cost, cultural beliefs, or personal risk evaluation. Physicians and other health care providers should provide non-judgemental support of the patient's decision.
HIV-Positive Woman and HIV-Negative Man
- For serodiscordant couples in which the woman is HIV positive, it is preferable to attempt home insemination with the partner's sperm during ovulation for 3 to 6 months before considering other methods. (III-A)
- If home insemination is unsuccessful, couples should be referred to a gynaecologist for consultation and then to a fertility specialist for a complete fertility work-up and appropriate treatment when necessary, including counselling on all assisted reproductive technologies if pregnancy is not achieved in 6 to 12 months. (III-A)
HIV-Positive Single Woman or HIV-Positive Woman in a Same-Sex Relationship
- Single HIV-positive women or HIV-positive women in a same-sex relationship should be referred to a fertility specialist and should consider the option of intrauterine insemination with HIV-negative donor sperm. This option is preferred over home insemination with donor sperm because the cost of sperm is high and intrauterine insemination performed in a fertility clinic has a higher success rate than home insemination. If sperm from a known donor is used for intrauterine insemination, regulations applicable to the donation of sperm must be followed. (III-A)
HIV-Positive Man and HIV-Negative Woman
- Serodiscordant couples in which the man is HIV positive should be referred to a fertility specialist and should consider the preferred option of sperm washing with intrauterine insemination. (II-2A)
- If intrauterine insemination is unsuccessful, couples should consider in vitro fertilization or intracytoplasmic sperm injection with either sperm washing or the use of donor sperm. (II-3A)
- HIV-positive men who do not require combination antiretroviral therapy for their own health should be encouraged to initiate combination antiretroviral therapy during the pre-conception period to reduce HIV plasma viral load, which can reduce the risk of HIV transmission to their HIV-negative partner. (II-3B)
HIV-Positive Single Man or Male Same-Sex Couple
- HIV-positive single men or men in same-sex relationships who have an HIV-negative or HIV-positive surrogate should be referred to a fertility specialist. (III-A)
HIV-Positive Man and HIV-Positive Woman
It is common for seroconcordant couples to attempt natural conception, especially if both partners have fully suppressed viral loads. Seroconcordant couples may wish to consider intrauterine insemination with sperm washing to reduce the potential risk of super-infection or transmission of drug-resistant strains of HIV between partners.
- Timed natural conception is recommended for seroconcordant couples who are taking combination antiretroviral therapy and who have fully suppressed HIV plasma viral loads. (II-3A)
- Seroconcordant couples should be counselled on the risks and benefits of timed natural conception (including HIV superinfection and transmission of drug-resistant strains of HIV). (II-3A)
- If timed natural conception is unsuccessful, couples should be referred to a gynaecologist for consultation and then to a fertility specialist for a complete fertility work-up and appropriate treatment when necessary, including counselling on all assisted reproductive technologies. (III-A)
Infertility Investigations and Treatment
Historically, fertility clinics in Canada have been reluctant to provide fertility investigation and treatment to HIV-positive people. Fertility experts concur that this has likely been due to a lack of information about HIV and its successful treatment coupled with a concern that serving HIV-positive people could deter HIV-negative individuals from accessing services. In 2010, the American Association of Reproductive Medicine released a statement in which it endorsed the provision of fertility services to all HIV-positive individuals.
- HIV-positive people should be counselled about fertility problems that occur in the general population, including genetic disorders and advancing maternal age. (III-A)
- Infertility investigations and treatment should be offered to HIV-positive people if required. (III-A)
- All decisions about combination antiretroviral therapy during the pre-conception period and during pregnancy should consider the health of the HIV-positive person and reduction of the risk of horizontal and vertical transmission of HIV. Decisions about combination antiretroviral therapy should be made in consultation with an HIV specialist. (III-A)
HIV Infection Control in Fertility Clinics
- Fertility laboratories should follow Canadian Standards Association guidelines for infection control when handling HIV-positive materials. (III-A)
- Potentially infectious materials should be stored in segregated containers and incubators to reduce the risk of HIV contamination. (III-A)
- Bio-containment straws for specimen storage should be used to further reduce the risk of cross-contamination of samples. (III-A)
Quality of Evidence Assessment*
I: Evidence obtained from at least one properly randomized controlled trial
II-1: Evidence from well-designed controlled trials without randomization
II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group
II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.
Classification of Recommendations†
A. There is good evidence to recommend the clinical preventive action
B. There is fair evidence to recommend the clinical preventive action
C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making
D. There is fair evidence to recommend against the clinical preventive action
E. There is good evidence to recommend against the clinical preventive action
L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making
†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.