I take 6 months approximately to treat male HIV-positive man with ART. And once he is investigated and treated for other sexually transmitted diseases, I prescribe TDF + FTC combination pill before and after Intra Uterine Insemination (IUI) to uninfected partner. Results are promising after 3 IUI.
Dr Raj Harjani Mumbai INDIA – 2/3/2013
Cool. Did we get the confimation levels of viral loads before IUI?
Dr Adegboye, NIGERIA – 2/17/2013
We confirm with plasma viral load. once undetectable for at least 2 months, then we consider person fit for sperm wash. Generally all male serodiscordant couples achieve undetectable levels by 4 months.
Dr Raj Harjani Mumbai INDIA – 2/25/2013
In my practice, I have several times come across discordant couples. But the difference with John and Sally’s case is that over 90% of my cases have been HIV advanced with children and irregularly practicing protected sex. We are living in a gender inequality culture where sex practice is male initiative, while woman, regardless her HIV status has no power to oppose her partners choice in term of safer sex practice. In our experience, women are more adherent to treatment than men. At our ARTClinic, discordant couples coming together for review can be estimated as less than 5%, among them those preoccupied about having safely children. We attempt to encourage them to report for routine review visits at ART clinic as a couple for proper IEC (information, education and communication) more especially for discordant couples. The concept of PrEP for uninfected HIV partner is not yet in practice in our ART clinic. We need to start now this important program targeting the concerned couples.
muhemedi – 1/17/2013
I love Joels categorization of the 3 approaches and will quote it widely.
David A. Wohl, MD – 11/11/2012
This question just came up with a male patient of mine who is suppressed and wants to have a child with his HIV-negative wife. They have been scrupulous about using condoms. I described 3 approaches, which I called “safe,” “extremely safe,” and “ridiculously safe.” The “safe” approach is to have unprotected intercourse during times of maximum fertility (determined by home ovulation monitoring), based on the fact that suppressive ART was 96% effective in HPTN 052 (and having an undetectable viral load was 100% effective, something that is less often mentioned). The “extremely safe” approach is to add courses of PrEP for his wife during times of attempted conception. The “ridiculously safe” approach is to use sperm washing. My patient and his wife are inclined to take the middle approach, which seems like a good choice to me. Some have also suggested conceiving by home artificial insemination with a syringe rather than actual intercourse to reduce vaginal trauma, though this seems unnecessary if you’re combining ART and PrEP.
Joel E. Gallant, MD, MPH – 10/29/2012
This is an interesting clinical scenario encountered frequently, and providing concrete answers through data support and clinical trials will definitely help couples to make decisions, and help consulting and treating physicians to provide more precise data for that purpose.
Doctor “T” – 10/24/2012
I agree with Dr T. One question is whether the belt and suspenders approach of ART for him and PrEP for her would offer anything more than ART for John alone? The calculus gets more complex when adding in potential toxicity of tenofovir in Sally (reduced BMD, for instance) and financial cost of PrEP. Short term use during attempts at conception may be more feasible. For the couples I have seen (most often an HIV+ patient of mine and his uninfected partner), the major issue has been access as these folks have no insurance.
David A. Wohl, MD – 10/28/2012
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Which of the following best summarizes your personal experience prescribing oral tenofovir/emtricitabine for PrEP?