Over the past 30 years, the landscape has changed dramatically for persons with HIV, particularly those who desire children. Before 1994, when the use of antiretrovirals was found to prevent perinatal transmission, women with HIV were often discouraged from getting pregnant and, in many cases, encouraged to undergo sterilization. Since that time, combination antiretrovirals with viral suppression has decreased both vertical and sexual transmission dramatically. HIV-affected couples have similar reproductive desires as those without HIV ; 50% of pregnancies are unplanned in both populations. Thus, preconception counseling to assist in planning pregnancies safely is recommended. Data suggest the risk of HIV transmission to a sexual partner is close to zero during condomless intercourse during fertile days in conjunction with treatment as prevention, where the HIV-infected partner is on HIV treatment with an undetectable viral load. The risk of sexual HIV transmission may be further decreased with the use of preexposure prophylaxis (PrEP) for the uninfected partner. PrEP is now recommended by the Centers for Disease Control and Prevention and the World Health Organization as one of several options of safe conception for HIV-serodifferent couples.

The use of medically assisted procreation (MAP) had been demonstrated to almost eliminate HIV transmission when used by serodifferent couples. However, MAP is limited by high cost and a paucity of centers that are available and willing to offer these services to persons with HIV.

The analysis by Mabileau et al suggests that, in HIV+ male/HIV– female serodifferent couples, condomless sexual intercourse that is limited to fertile days along with PrEP is associated with a transmission risk close to zero. This strategy provides a risk reduction similar to MAP but at substantial cost savings and less medical intervention.

We commend the authors’ conclusion that a substantial decrease in the cost of PrEP would allow this strategy to be cost-effective, given its high efficacy. The PrEP study demonstrated 80% adherence in women who used PrEP during the periconception period. Assuming that these adherence levels would be replicated in nonstudy environments, the use of PrEP for this indication would be cost-effective.

As seasoned clinicians in this field, we are excited to see how the landscape has expanded over time with multiple effective interventions to achieve parenthood safely. We advocate that clinics universally offer PrEP in conjunction with treatment as prevention during attempted conception among serodifferent couples who seek care and that the cost of PrEP be reduced substantially to ensure access to this strategy.