For discordant couples, where one partner is HIV-infected and the other is not, conceiving a baby remains a big challenge.
However, Dr Sheila Eshiwani in charge of a discordant couples clinic at Kenyatta National Hospital, has said there are a number of safe conception plans that limit transmission of HIV to another partner. Recent studies have also shown high success rates. A recent Partner survey reported zero HIV transmissions after 800 couples had sex more than 58,000 times without a condom, when the positive partner had an undetectable viral load.
Dr Eshiwani said when a discordant couple first visit the clinic, they are counselled and medical examinations done.
‘‘Then we offer them various options of conception,” she said, adding that despite HIV being a cause of infertility among couples, there are treatments that ensure conception.
The clinic, the only of its kind in the country, was started in 2013 to help discordant couples end the stigma of not having children that thousands of affected families face.
The options of conceiving among discordant couples depend on who in the relationship is the positive partner.
1. Anti-HIV drugs
In this treatment plan, the HIV negative partner takes anti-HIV drugs to reduce chances of contracting the virus. This is called Pre-exposure prophylaxis (PrEP).
“PrEp which consists of taking a combination of three drugs (tenofovir, emtricitabine and lamivudine) combined into one tablet is one intervention measure. The HIV negative partner takes one pill a day for at least seven days prior to having sexual intercourse,” said Derek Okal, a counselling psychologist.
This method is considered best when the positive partner is taking ARV drugs and virally suppressed, meaning that the amount of HIV in the blood is very low, has no multiple partners and when not using a condom.
Doctors, however, insist that the couple should wait until the positive partner has taken the ARV drugs consistently for at least six months and have a viral load of less than 1,000 copies, which is the amount of HIV circulating per millilitre of the blood.
‘‘More than 1,000 copies means ARV treatment failure which needs to be investigated,’’ said Dr Eshiwani.
Timed unprotected intercourse that is limited to the fertility days is then proposed and folic acid supplements given.
The partner who is negative is given a package of care where they are required to take renal tests as well as Hepatitis B and pregnancy tests before being put on medication.
It is recommended that one should not take PrEP for life, but only for the period one thinks he/she is at risk of contracting HIV.
Dr Eshiwani said PrEP is the most successful method used amongst discordant couples as it is offered for free at the clinic.
2. Sperm wash
This method is done when the male is the positive partner. It is also done when the man is not virally suppressed and for those whose partners do not want to be on ARVs.
In this case, a semen analysis is done and then the semen is separated from the sperms as the virus is said to only be present in semen. A concentration of the male sperm is then collected and injected into the uterus. This can take more than one attempt to achieve the results.
This must be done at a hospital and is an expensive procedure charged between Sh50,000 and Sh80,000 in private facilities. University of Nairobi offers the procedure for Sh8,000.
3. Vaginal insemination
If the female is the positive partner, this is the easiest procedure for conception. Here, the couple will have intercourse using a special condom that they will be given at the health facility.
After that, they will be given a special syringe that will be used in injecting the semen into the vagina. This should be done immediately but might require one to repeat the procedure a couple of times to boost the rate of success.
This is when the infected spouse consistently takes anti-retroviral drugs (ARVs) up to the time when the viral load is low, and they can be allowed by the doctor to have unprotected sex for the purpose of conception.
However, this method is discouraged by doctors because most people disregard the importance of going for counselling and care in hospitals by performing this procedure alone.
Mr Okal said anybody who takes ARVs for about six months consecutively is likely to have viral suppression, meaning that the virus count in the blood is low that it cannot be detected by testing.
This means the infected spouse is less likely to infect the other and unprotected sex can be allowed after a test is done to establish this.
As a rule, the couple should be using protection every time, but after undergoing the viral load test, they can have unprotected sex.
Doctors, however, insist that discordant couples should get counselling and treatment in hospitals as there are cases of self-prescription, especially amongst homosexuals and sex workers in their quest to reduce their chances of contracting HIV.
However, in some cases, when after six months of unsuccessfully trying to conceive, other tests such as tubal blockage, hormonal profile, semen analysis and scrotal ultrasound are done to ensure there are no impediments to these procedures.
After successful conception through a confirmatory test, HIV test is done for both partners and the mother is expected to attend prenatal clinics.
For those taking PrEp drugs, they continue with the treatment throughout the pregnancy. Once the child is born, then they are put on ARV drugs for six weeks and tested at birth and after six weeks for the HIV virus.
Discordant Couples Care Clinic
Dr Eshiwani said the Kenyatta National Hospital clinic has carried out numerous successful conception procedures.
“The clinic has had about 600 discordant couples and we have not had any case of sero-conversion while receiving treatment and while trying to conceive,” she said, adding that 40 per cent of the procedures had been successful with a majority being cases of infertility due to HIV.
There are instances when the positive partners have a viral load of more than 1,000 even after taking ARV drugs. Dr Eshiwani said in such as case the conception procedure is stopped until the viral load is less than 1,000.
Other instances are when one develops HIV, kidney problems or when the negative partner is not adherent to the treatment.
Other than conception services, the clinic also provides counselling services for discordant couples and especially those who do not know how to break the news to their partners on their status.