#AIDS2016 Safer conception for men and women living with HIV and their partners Key issues and considerations for widespread implementation Dr Natasha Davies University of the Witwatersrand, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa

#AIDS2016 Outline Background The need The options Considerations for implementation Way forward

#AIDS2016 Background 256 couples Low cost Low tech

#AIDS2016 Context determines approach Infertility assessment Relationship dynamics Risk versus reproductive desires Risk Desire PrEP STI screening Viral loads

#AIDS2016 The need PLHIV living longer, healthier lives 20-50% PLHIV desire children Pregnancy rates increase with ART PLHIV take risks to have children Kaida et al, 2010 Cooper et al, 2009 Homsy et al, 2009 Schwartz et al, 2011 Westreich et al, 2012 Myer et al, 2010 Ngure et al,2014 Awiti, 2010 Brubaker et al 2011

#AIDS2016 Safer conception defined Support men and women affected by HIV to SAFELY fulfil their reproductive rights and desires – WHEN they want – HOW they want Patient Preferences

#AIDS2016 Evidence-based options Treatment as prevention Timed condomless sex Vaginal self- insemination Medical male circumcision Fertility assessment Sperm washing & assisted reproductive technology PrEP STI screening and treatment

#AIDS2016 Are we overcomplicating it? Safer conception strategies can be – Easy – Cheap – Low technology Do we still need the belt and braces approach?

#AIDS2016 Three key considerations 1. PrEP 2. Sperm washing 3. Fertility assessment

#AIDS2016 PrEP For many couples may add <1% benefit Consider use for – ‘Bridging’ – Low ART adherence – Unknown partner status/multiple partners – Reducing anxiety Discuss continued use if pregnancy achieved Hoffman et al, 2015 Price et al, 2016 Baeten et al, 2015

#AIDS2016 Sperm washing and assisted reproductive techniques Very safe BUT More effective than viral suppression? Costly Compromises pregnancy success if normal fertility Creates anxiety Limited availability Should providers routinely offer this option?

#AIDS2016 Fertility assessment Infertility rates higher at baseline Tailored strategies Reduced HIV risks Costs Complex for providers Anxiety Pathologizes process

#AIDS2016 A tailored approach Establish what is ‘ENOUGH’ for each couple

#AIDS2016 The way forward

#AIDS2016 Creating demand Reframe family planning messaging Encourage provider- client conversations Community awareness Address stigma Demand Creation Strategies

#AIDS2016 Ensuring supply Translating KNOWLEDGE into PRACTICE Integrate safer conception into 90:90:90 and EMTCT programs

#AIDS2016 Equipping healthcare providers Spread the word Provide support Clinical framework Address attitudes Start measuring Keep it simple

#AIDS2016 Acknowledgements RHI Safer conception and implementation science teams Hillbrow community healthcare centre department of health staff All the safer conception service clients Saiqa Mullick, Sheree Schwartz, Michelle Moorhouse and Professor Helen Rees for their inputs