Pre-Exposure Prophylaxis Gives Way to New Options in Family Planning

Susan and Dan Hartmann are a serodiscordant couple who had an HIV-free baby without the use of pre-exposure prophylaxis.

Dan and Susan Hartmann

In the United States, pre-exposure prophylaxis (PrEP) has recently given discordant couples another option when it comes to sexual contact. Early in the HIV/AIDS epidemic, public health officials emphasized condoms or abstinence as the most effective means of preventing HIV transmission between romantic partners. In 2014, the U.S. Centers for Disease Control and Prevention (CDC) issued new guidelines recommending that the partner in a discordant relationship who is HIV-negative consider using PrEP in the form of a daily pill to fight the transmission of HIV. Findings from current research, presented at last week’s Conference on Retroviruses and Opportunistic Infections (CROI), have continued to mount strong evidence supporting PrEP as a safe and effective means to prevent HIV transmission.

Dan and Susan Hartmann, who appeared on CNN on World AIDS Day 2014, recently spoke to the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), about their life as a discordant couple (Dan is HIV-positive, but Susan is not). They see PrEP as a substantial step forward. While much of the news coverage of PrEP has focused on its application in same-sex relationships, Dan and Susan see the drug as revolutionary for heterosexual couples who wish to have children.

PrEP was not an option for them when the Hartmanns conceived their daughter, Ryan, six years ago. They used “timed intercourse,” planned sexual encounters without condoms at times when Dan’s viral load was undetectable from heavy use of antiretroviral drugs and Susan was at peak fertility. Today they would include PrEP in their planning.

“It seems to me that HIV has really been dominated by conversations about men and sex,” says Susan. “What PrEP can also allow is a woman-focused HIV-prevention. PrEP can empower women to make decisions around their own protection for themselves and their children—and that is very different than just having a man put on a condom.”

“PrEP can be an important protective additional measure for couples who want children and in which one partner is HIV-negative and the other HIV-positive,” confirms Lynne Mofenson, senior HIV technical advisor at EGPAF. “But the most important protection measure is for the partner with HIV to be receiving antiretroviral therapy and have undetectable viral load. In such situations, the risk of transmission is extremely low, and it is unclear if PrEP is needed for additional protection.”  

Truvada, the drug used in PrEP, costs as much as $14,000 per year in the United States—not to mention the expenses of quarterly testing and lab work. PrEP remains out of reach for many couples, especially those living in low-resource areas where HIV prevalence tends to be highest. However, as Mofenson points out, discordant couples can still prevent transmission of HIV between partners by ensuring partners know each other’s HIV status and by ensuring that the infected partner is receiving antiretroviral therapy with undetectable viral load.

“Our focus at EGPAF remains ensuring that everyone knows their HIV status and that HIV-infected individuals in discordant couples receive and adhere to treatment,” says Mofenson.