Background: Safer conception strategies--ART for HIV-positive partners, PrEP for HIV-negative partners, timed condomless sex, self-insemination and male medical circumcision--empower couples affected by HIV trying to conceive to minimize HIV transmission risk to partners and potential children. We report outcomes from the Sakh''umndeni demonstration project, one of the first safer conception clinics in sub-Saharan Africa.
Methods: Adults trying to conceive and in relationships in which at least one partner was HIV-positive were enrolled into safer conception care at Witkoppen Clinic in Johannesburg, South Africa, between July 2013-July 2017. Patients were provided tailored safer conception care by a nurse. Time-to-first pregnancy was estimated using Kaplan-Meier curves; women who did not conceive were censored at date of termination or last follow-up visit.
Results: 526 individuals (334 women/192 men) from 334 partnerships participated. Couples were serodifferent (n=164, 49%), seroconcordant (n=147, 44%) or in relationships with one unknown status partner (n=23, 7%). Median ages of women and men were 34 [IQR:30-38] and 37 [IQR:33-42] respectively. At baseline, 64% of HIV-positive women and 45% of HIV-positive men were virally suppressed (< 50copies/ml). It took couples a median of 4.0 months [IQR:1.7-7.7] to be given the go-ahead to start trying to conceive. In total, 98 pregnancies among 88 women were observed. Pregnancy incidence was 47.9/100 person-years (95%CI:38.9,59.1). HIV-positive women were 52% less likely to conceive as HIV-negative women (IRR:0.48, 95%CI:0.28,0.87). Median time-to-pregnancy was 0.8 years for HIV-negative and 2.1 years for HIV-positive women (Figure). At time of pregnancy, most HIV-positive women were virally suppressed (63/75 [84%] < 50 copies/ml and 74/75 [99%] < 1000 copies/ml]. Of the 98 pregnancies, 66 (67%) delivered a baby, 24 (25%) had a miscarriage or ectopic pregnancy, 5 (5%) were still pregnant and 3 (3%) unknown. No horizontal or vertical HIV transmissions were observed.
Conclusions: HIV-positive women were less likely to conceive than HIV-negative women and risk of miscarriage was high. Prolonged attempted conception highlights the need for approaches to reduce onward transmission risks, particularly as viral suppression among patients trying to conceive on ART cannot be assumed. Safer conception strategies can help couples successfully conceive an HIV-free child without jeopardizing their own or partner''s health.

Time-to-pregnancy among women enrolled in safer conception care, Johannesburg, South Africa
[Time-to-pregnancy among women enrolled in safer conception care, Johannesburg, South Africa]