U=U and Safe Conception for Serodiscordant Couples

Evidence Supporting U=U (Undetectable = Untransmittable)

Treatment as prevention with sustained viral suppression for 6 months eliminates sexual transmission risk when the HIV-positive partner maintains an undetectable viral load 1

Both partners should be screened and treated for any sexually transmitted infections before attempting conception, as recommended by the Centers for Disease Control and Prevention 2
Use ovulation predictors to limit unprotected intercourse to peak fertility periods, as suggested by the Clinical Infectious Diseases guidelines 2
Continue consistent condom use except during fertile window attempts, as recommended by the Clinical Infectious Diseases guidelines 2
If the male partner is HIV-positive and female is uninfected, consider pre-exposure prophylaxis (PrEP) for the uninfected female partner during conception attempts, as recommended by the Clinical Infectious Diseases guidelines 2
If the female partner is HIV-positive and male is uninfected, home artificial insemination (vaginal insertion of ejaculate with a syringe) effectively avoids risk to the uninfected male partner, as suggested by the Clinical Infectious Diseases guidelines 2

The HIV-positive partner must maintain undetectable viral loads throughout conception attempts and pregnancy, as recommended by the JAMA guidelines 1
HIV RNA monitoring should occur every 3 months until suppressed for at least 1 year, then can be reduced to every 6 months if clinically stable, as recommended by the JAMA guidelines 3
Do not assume zero risk exists if viral suppression has not been sustained for the full 6 months, as warned by the JAMA guidelines 1
Do not recommend spermicides, as these increase HIV transmission risk, as warned by the Clinical Infectious Diseases guidelines 4
Avoid medications with reproductive toxicity during conception attempts, particularly efavirenz which has teratogenic effects, as warned by the Clinical Infectious Diseases guidelines 4

Continue ART throughout pregnancy to prevent vertical transmission, as recommended by the MMWR Recommendations and Reports guidelines 5
The HIV-infected mother should not breastfeed to minimize vertical transmission risk, as recommended by the Clinical Infectious Diseases guidelines 2
The infant should receive appropriate post-exposure prophylaxis, as recommended by the MMWR Recommendations and Reports guidelines 5

Oral sex represents a significantly lower per-act risk for HIV transmission compared to receptive anal intercourse, insertive anal intercourse, and penile-vaginal intercourse 6
The risk hierarchy for sexual transmission (from highest to lowest risk) includes blood transfusion, needle sharing by injection drug users, receptive anal intercourse, insertive anal intercourse, penile-vaginal intercourse, and oral sex (substantially lower risk) 6

Suppression of HIV through antiretroviral therapy (ART) is highly effective in reducing—and largely eliminating—the risk of HIV transmission 7
The HPTN052 study demonstrated that ART reduced HIV transmission by more than 96% in serodiscordant couples 7
The PARTNER Study reported no HIV transmission over an estimated 894 couple-years of observation when the HIV-infected partner was on ART, even when condomless sex occurred 7

Consistent condom use is recommended for all sexual activities in serodiscordant couples to further reduce transmission risk 8
For couples planning conception, specialized approaches such as home artificial insemination can effectively avoid risk to an uninfected male partner 9

Spermicides containing nonoxynol-9 are contraindicated as they may increase the risk of genital lesions and potentially facilitate HIV transmission 10

HIV-negative partners in serodiscordant relationships should undergo regular HIV testing (every 3-6 months) 11

Assuming zero risk with oral sex - while the risk is lower, it is not zero, especially if the HIV-positive partner has a detectable viral load or if oral lesions are present 6
Inconsistent adherence to ART by the HIV-positive partner, which can lead to viral rebound and increased transmission risk 7