. 2018 Oct 18;19(1):915. doi: 10.4102/sajhivmed.v19i1.915

TABLE 4.

Summary of optimal risk reduction strategies for resource-limited and resource-intensive settings, according to the HIV status of the couple.

Partner	Seroconcordant (female and male HIV-positive)	Serodifferent (male HIV-positive, female HIV-negative)	Serodifferent (female HIV-positive, male HIV-negative)	Sero-unknown (one partner has unknown HIV status)
Female partner	ART recommended for six months before attempting pregnancy. Encourage high levels of adherence. CD4+ monitoring as per guidelines. Recommend CD4+ > 200 cells/mL prior to pregnancy attempts. If available, confirm undetectable viral load and monitor at least six-monthly. Timed condomless sexual intercourse where undetectable viral load unconfirmed or couple chooses as adjunct.	Repeat HIV testing before pregnancy attempts begin, throughout trying period and throughout pregnancy and breastfeeding. Begin trying once male viral load confirmed undetectable. Timed condomless sexual intercourse during fertile period where undetectable viral load unconfirmed or couple chooses as adjunct. Consider PrEP, particularly if male partner newly on ART (< six months), not engaged in ART care, adherence concerns or heightened anxiety or where viral load monitoring unavailable. Consider sperm washing and intrauterine insemination.^†,^‡	ART recommended for six months before attempting pregnancy. Encourage high levels of adherence. CD4+ monitoring as per national guidelines, recommended CD4+ > 200 cells/mL prior to pregnancy attempts. If available, confirm undetectable viral load^† and monitor at least six-monthly while attempting conception. Where undetectable viral load unconfirmed, or as an adjunct measure chosen by couples, timed condomless sex limited to peak fertile window or intravaginal self-insemination using condoms without spermicide or sperm collection with intrauterine insemination.^†	HIV-negative female with unknown male status: Repeat HIV testing throughout exposure period. Offer PrEP. Provide support to try and engage male partner. Timed condomless sexual intercourse. HIV-positive female with unknown male status: ART recommended for six months before attempting pregnancy. Encourage high levels of adherence. CD4+ monitoring as per national guidelines and recommend CD4 > 200 cells/mL prior to pregnancy attempts. If available, confirm undetectable viral load^† prior to beginning pregnancy attempts and monitor at least six-monthly while trying. Provide support to try and engage male partner. Timed condomless sexual intercourse once female viral suppression confirmed as male partner status unknown.
Male partner	ART recommended for six months before attempting pregnancy. Encourage high levels of adherence. CD4+ monitoring as per national guidelines. If available, confirm undetectable viral load and monitor at least six-monthly while attempting pregnancy.	ART recommended for six months before attempting pregnancy. Encourage high levels of adherence. CD4+ monitoring as per national guidelines. If available, confirm undetectable viral load^† before pregnancy attempts begin and monitor at least six-monthly while trying. May opt for sperm assessment and sperm washing with HIV PCR.^† Medical male circumcision may be offered.	Repeat HIV testing before pregnancy attempts begin, throughout trying and at end of window period from last exposure. Recommend male medical circumcision. Consider PrEP where female newly established on ART (< six months), not accessing treatment, no viral load monitoring available, adherence concerns or high levels of anxiety regarding HIV acquisition.	HIV-negative male with unknown female status: Repeat HIV testing throughout. Offer PrEP. Provide support to try and engage female partner. Timed condomless sexual intercourse. Encourage medical male circumcision. HIV-positive male with unknown female status: ART recommended for six months before attempting pregnancy. Encourage high levels of adherence. CD4+ monitoring as per national guidelines. If available, confirm undetectable viral load^† prior to pregnancy attempts and monitor at least six-monthly throughout pregnancy attempts. Provide support to try and engage female partner. Timed condomless sexual intercourse once male viral suppression confirmed as female status unknown.

Partner

Seroconcordant (female and male HIV-positive)

Serodifferent (male HIV-positive, female HIV-negative)

Serodifferent (female HIV-positive, male HIV-negative)

Sero-unknown (one partner has unknown HIV status)

Female partner

ART recommended for six months before attempting pregnancy.
Encourage high levels of adherence.
CD4+ monitoring as per guidelines. Recommend CD4+ > 200 cells/mL prior to pregnancy attempts.
If available, confirm undetectable viral load and monitor at least six-monthly.
Timed condomless sexual intercourse where undetectable viral load unconfirmed or couple chooses as adjunct.

Repeat HIV testing before pregnancy attempts begin, throughout trying period and throughout pregnancy and breastfeeding.
Begin trying once male viral load confirmed undetectable.
Timed condomless sexual intercourse during fertile period where undetectable viral load unconfirmed or couple chooses as adjunct.
Consider PrEP, particularly if male partner newly on ART (< six months), not engaged in ART care, adherence concerns or heightened anxiety or where viral load monitoring unavailable.
Consider sperm washing and intrauterine insemination.^†,^‡

ART recommended for six months before attempting pregnancy.
Encourage high levels of adherence.
CD4+ monitoring as per national guidelines, recommended CD4+ > 200 cells/mL prior to pregnancy attempts.
If available, confirm undetectable viral load^† and monitor at least six-monthly while attempting conception.
Where undetectable viral load unconfirmed, or as an adjunct measure chosen by couples, timed condomless sex limited to peak fertile window or intravaginal self-insemination using condoms without spermicide or sperm collection with intrauterine insemination.^†

HIV-negative female with unknown male status:

Repeat HIV testing throughout exposure period.
Offer PrEP.
Provide support to try and engage male partner.
Timed condomless sexual intercourse.

HIV-positive female with unknown male status:

ART recommended for six months before attempting pregnancy.
Encourage high levels of adherence.
CD4+ monitoring as per national guidelines and recommend CD4 > 200 cells/mL prior to pregnancy attempts.
If available, confirm undetectable viral load^† prior to beginning pregnancy attempts and monitor at least six-monthly while trying.
Provide support to try and engage male partner.
Timed condomless sexual intercourse once female viral suppression confirmed as male partner status unknown.

Male partner

ART recommended for six months before attempting pregnancy.
Encourage high levels of adherence.
CD4+ monitoring as per national guidelines.
If available, confirm undetectable viral load and monitor at least six-monthly while attempting pregnancy.

ART recommended for six months before attempting pregnancy.
Encourage high levels of adherence.
CD4+ monitoring as per national guidelines.
If available, confirm undetectable viral load^† before pregnancy attempts begin and monitor at least six-monthly while trying.
May opt for sperm assessment and sperm washing with HIV PCR.^†
Medical male circumcision may be offered.

Repeat HIV testing before pregnancy attempts begin, throughout trying and at end of window period from last exposure.
Recommend male medical circumcision.
Consider PrEP where female newly established on ART (< six months), not accessing treatment, no viral load monitoring available, adherence concerns or high levels of anxiety regarding HIV acquisition.

HIV-negative male with unknown female status:

Repeat HIV testing throughout.
Offer PrEP.
Provide support to try and engage female partner.
Timed condomless sexual intercourse.
Encourage medical male circumcision.

HIV-positive male with unknown female status:

ART recommended for six months before attempting pregnancy.
Encourage high levels of adherence.
CD4+ monitoring as per national guidelines.
If available, confirm undetectable viral load^† prior to pregnancy attempts and monitor at least six-monthly throughout pregnancy attempts.
Provide support to try and engage female partner.
Timed condomless sexual intercourse once male viral suppression confirmed as female status unknown.

PrEP, pre-exposure prophylaxis; ART, antiretroviral therapy; PCR, polymerase chain reaction.

Note: HIV testing and retesting to be conducted as per national guidelines and with high level quality assurance of testing processes. All female partners, regardless of HIV status, should be started on folic acid supplementation (per local guidelines) prior to undertaking pregnancy attempts.

^†

, Options that are more commonly available in resource-intensive settings, although they may be available in resource-limited settings as well.

^‡

, Costly, may not improve HIV prevention, reduced conception rates per cycle compared with natural conception in couples where no fertility issues are identified.