It is possible for people living with Human Immunodeficiency Virus (HIV) to have children safely. Modern medicine, particularly the widespread use of Antiretroviral Therapy (ART), has transformed the landscape of HIV, allowing individuals to live long, healthy lives and pursue parenthood with minimal risk of transmitting the virus. The foundation of this safety is the scientific consensus known as Undetectable = Untransmittable (U=U). U=U states that an HIV-positive person who achieves and maintains a viral load so low it cannot be detected cannot sexually transmit HIV. This suppression forms the basis for successful strategies for conception, pregnancy, and postnatal care, making the risk of mother-to-child transmission less than one percent in high-resource settings.
Achieving Conception Safely
The primary goal for any couple where one or both partners are HIV-positive and planning a pregnancy is to ensure the HIV-positive partner has an undetectable viral load. Healthcare providers typically recommend that the HIV-positive partner be on effective ART for at least six months, with a confirmed undetectable viral load, before attempting conception. This step is paramount, as it eliminates the risk of sexual transmission to the negative partner.
For couples where one partner is HIV-positive and the other is HIV-negative, known as serodiscordant couples, conception can often be done through timed, condomless intercourse around the time of ovulation. Since the HIV-positive partner is virally suppressed (U=U), the risk of transmission is effectively zero. The HIV-negative partner may also choose to use Pre-Exposure Prophylaxis (PrEP) as an additional layer of protection.
If the HIV-positive partner is unable to achieve or maintain viral suppression, or if the couple prefers an alternative, assisted reproductive technologies (ARTs) can be utilized. These methods can include sperm washing, where sperm is separated from seminal fluid, followed by intrauterine insemination (IUI) or in vitro fertilization (IVF). These clinical interventions provide a highly controlled environment to minimize any theoretical risk, ensuring the safety of the HIV-negative partner and the future child.
Protecting the Baby During Pregnancy and Birth
Once pregnancy is confirmed, the continuous use of Antiretroviral Therapy (ART) by the mother is the most important factor in preventing mother-to-child transmission (MTCT). The medication regimen works to reduce the amount of HIV in the mother’s blood and across the placenta, which significantly limits the baby’s exposure to the virus. Regular monitoring of the mother’s viral load is performed throughout the pregnancy to confirm that the suppression is being maintained.
The mode of delivery—vaginal birth versus cesarean section—is determined by the mother’s viral load near the time of delivery, typically measured around 36 weeks of gestation. If the mother’s viral load is confirmed to be at or below 1,000 copies per milliliter, a vaginal delivery is generally considered safe.
For mothers whose viral load is above 1,000 copies per milliliter, or if the viral load is unknown, a scheduled cesarean section at 38 weeks is recommended. This surgical delivery is performed to reduce the baby’s exposure to the mother’s blood and genital secretions during labor. In some cases, the mother may also receive intravenous Zidovudine (AZT), an antiretroviral medication, beginning several hours before the procedure. This intrapartum medication saturates the fetal circulation, providing an extra shield against potential transmission during birth.
Newborn Testing and Postnatal Care
Immediately after birth, the infant begins a course of prophylactic antiretroviral medication, regardless of the mother’s viral load. The most common regimen is a liquid dose of Zidovudine administered as soon as possible, ideally within six to twelve hours of delivery. The duration of this treatment is typically two to six weeks, depending on the mother’s viral load during pregnancy and delivery.
Testing the newborn for HIV is done using nucleic acid tests (NATs), such as the HIV DNA Polymerase Chain Reaction (PCR), which detects the virus’s genetic material. Antibody tests are not used for diagnosis in newborns because a baby passively acquires the mother’s HIV antibodies, which can lead to a false positive result. The initial diagnostic testing schedule usually involves a test at birth or within 48 hours, a second test at one to two months of age, and a final test at four to six months of age to definitively confirm the baby’s HIV status.
Regarding infant feeding, current guidelines in high-resource countries generally recommend formula feeding to eliminate the possibility of transmission through breast milk. While ART greatly reduces the risk of transmission via breast milk, a small risk remains. If a mother is fully suppressed and strongly desires to breastfeed, shared decision-making with a healthcare team is necessary, including strict adherence to ART and frequent viral load monitoring for both mother and infant.