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Treatment in couples with serodiscordant HIV

The infection by the human immunodeficiency virus (HIV), is today a universal epidemic and nowadays, its main transmission routes are sexual and perinatal (from mother to child during pregnancy). Advances in the treatment of HIV have allowed improving the quality and life expectancy of patients.

When a stable partner, with one or both of their infected members, decides to schedule a pregnancy, the family doctor acquires a transcendental role: providing qualified information so that the couple can make appropriate decisions. In these cases, the opposition between safe sex and the possibility of conception poses real challenges for the health team. The academic and ethical recommendations regarding fertility treatments for these patients are not well defined.

From the first years of identification of HIV it is known that it is present as a free virus and incorporated into the pool of cells of genital secretions. Its presence in these fluids is intermittent and is not related to the stage of the disease or the magnitude of the viral load in the plasma (amount of HIV virus circulating in the blood). Although some reports mention the presence of HIV particles in the sperm, conclusive evidence has not been established to date that this cell could be an infectious agent.

From 1989, medical research began to appear with experiences of assisted insemination in discordant couples (infected man-uninfected woman). The procedures performed, consisting of centrifuges, washes and separation procedures by gradients (Swim-up, Percoll, etc.), separate the cells and free virus from the sperm.

The gynecology teams with experience in assisted reproduction began to offer discordant couples: HIV (+) man and HIV (-) woman, this therapeutic option with encouraging results. So far there have been no reported cases of infection in mothers or children undergoing this procedure. In the healthcare practice, patients carrying this infection have proposed counseling in relation to possibilities of procreation. This situation has led to the formation of interdisciplinary teams, composed of clinicians, infectious disease specialists in HIV infection and gynecologists specializing in assisted reproduction to provide an appropriate alternative that would allow the possibility of conception, decreasing the possibility of infection.

In cases where the woman is infected with the virus and the man is not, there are also possibilities of treatment, but previously an effective antiviral treatment must be implemented to reduce the viral load to a minimum, since in these cases the main risk is the “vertical” transmission (from mother to fetus) during pregnancy. With the current treatment regimes, that probability is less than 1%, so it is possible, today, to enjoy motherhood, provided that the mother is perfectly controlled and treated beforehand.

When both partners are infected, the current recommendation of infectious diseases is to continue having protected sexual relations as there is a possibility that the partners are infected with different subtypes of HIV virus. Therefore, in many of these cases, it may be necessary to resort to Assisted Reproduction.