A new pill could enable people living with HIV to conceive children through sex without risking the health of their HIV-negative partner.
HIV and pregnancy is not a topic we hear a lot about in Australia. But the incredible success of antiretroviral treatment (ART) means most Australians diagnosed with HIV assume a long and healthy life, along with the milestones of sex, relationships and family.
In 2012-13, 108 children were born to HIV-positive mothers, up from 50 in 2004-05. While we don't have the data for children born to HIV-positive fathers, there are likely to be many more.
The well-managed use of ART means mother-to-child transmission of HIV is rare in Australia.
For a person living with HIV, however, achieving a pregnancy is not without its complications. Condoms are central to safe sex – the main protection against transmission of HIV – but of course condoms also protect against pregnancy.
For heterosexual people in a sero-discordant relationship (where one person is HIV-positive, the other HIV-negative), options for conceiving children have tended to be either expensive or risky. At the expensive end are fertility treatments, such as sperm washing and in vitro fertilisation.
At the riskier end, many couples take a chance on sex without a condom. If the HIV-positive partner is on ART and the virus has been suppressed in their system, then recent studies suggest this can be a relatively safe option.
But a new drug could make this risk virtually negligible. Pre-exposure prophylaxis (PrEP) is a course of a combination ART drug called Truvada that HIV-negative people take to prevent them becoming infected.
Research has so far shown that, taken correctly, PrEP significantly reduces a person's chance of acquiring HIV. PrEP has been described as a sexual game-changer: a pill that re-introduces the possibility of "safe" sex without condoms.
For this reason, the emergence of PrEP has been controversial – particularly within the gay community. In a now-infamous 2012 Huffington Post piece, writer David Duran coined the term "Truvada whores" – pointing largely to gay men who, Duran argued, will use PrEP simply to continue having unsafe sex.
Others have echoed Duran's sentiment, citing concerns that PrEP provides licence to be irresponsible, undermining years of effort to legitimise condom use and risking an increase in rates of other sexually transmitted infections.
But PrEP has more supporters than critics. While it might not offer a global solution to stopping HIV, it certainly presents an effective prevention option for people at high risk of acquiring HIV.
For sero-discordant couples wanting to conceive children, PrEP is undoubtedly a game-changer, allowing natural conception with minimal risk. Evidence to date supports the safety and efficacy of PrEP for sero-discordant couples trying to conceive and it's seen as a sensible choice.
But people living with HIV and their partners still encounter stigma if they decide to have children.
In her book on HIV and pregnancy, Positively Negative, journalist Heather Boerner recounts the story of Poppy Morgan (not her real name), an American woman with a HIV-positive partner. In 2010, Morgan's doctor refused to prescribe PrEP and told her that if she continued with her plan to conceive a child, she would no longer treat her.
To be fair, in 2010 there was limited information available about PrEP and this doctor may well have been acting out of concern for Morgan. But Morgan felt shamed by this encounter and judged for her sexual choices and maternal longing.
This is not uncommon. In her Australian-based research with HIV-positive women, Karalyn McDonald found many women had friends or family who objected to their decision to have children, arguing it was selfish and put children at risk. One woman in the study told people she had fallen pregnant accidentally to avoid having to justify her decision to pursue a second pregnancy.
While Truvada may currently be prescribed to HIV-positive Australians, its use as a preventive treatment for HIV-negative people has not yet been approved, though the manufacturer has submitted an application to the Therapeutic Goods Administration.
If approved for use, Truvada will need to be assessed by another body to determine whether it will be subsidised under the Pharmaceutical Benefits Schedule. Otherwise the cost will be around A$800 per month.
While PrEP may not radically change the landscape of HIV prevention in Australia – condoms will always be important – it will certainly provide a significant new reproductive option for people living with HIV.
But conception is only the first step toward parenthood. There is a need to promote respectful understanding of the reproductive and parenting choices made by people living with HIV. Challenging stigma is an ongoing concern.
This article was originally published in The Conversation.
Jennifer Power is a research fellow at Australian Research Centre for Sex, Health and Society.