What are the risks of complications or factors that can impact birth or a new pregnancy in a couple where the husband is HIV (Human Immunodeficiency Virus) negative, taking PrEP (Pre-Exposure Prophylaxis), and has a history of HSV-2 (Herpes Simplex Virus Type 2) in remission, and the 27-year-old wife has a history of substance use disorder, now in recovery?

From the Guidelines

The couple should proceed with caution and consult healthcare providers about the husband continuing PrEP during conception attempts, managing HSV-2 to prevent outbreaks, and addressing any lingering health effects from previous drug use through comprehensive prenatal care and possibly additional screenings. When considering pregnancy, several factors come into play for a couple where the husband is taking HIV PrEP, is HIV-negative but HSV-2 positive (in remission), and both partners have a history of drug use but are currently sober.

• The HIV PrEP medication (typically Truvada or Descovy) poses minimal risk to pregnancy, as studies have not shown significant adverse effects on fertility or fetal development 1.
• Regarding HSV-2, if the husband is in remission with no active outbreaks, the risk of transmission to the mother during conception is low. However, if the mother contracts HSV-2 during pregnancy, especially in the third trimester, there is a risk of neonatal herpes, which can be serious for the newborn.
• For the mother's history of drug use, even though she is currently sober, previous substance use may have affected her overall health, potentially impacting pregnancy outcomes. Regular prenatal care is essential to monitor for complications like preterm birth, low birth weight, or developmental issues.
• Both partners should maintain sobriety throughout the pregnancy, as substance use can significantly impact fetal development.
• The couple should be aware of the potential risks of HIV transmission and the importance of continued PrEP use, as well as the management of HSV-2 to prevent outbreaks.
• Preconception counseling is crucial for HIV-1-infected women, including selection of effective contraceptive methods, education about perinatal transmission risks, and initiation or modification of antiretroviral therapy 1.
• The couple should also consider the general principles regarding the use of antiretroviral agents in pregnancy, including coordination and communication between the HIV specialist and the obstetrician 1.
• According to the guidelines for the management of persons infected with human immunodeficiency virus, the prevention of mother-to-child transmission of HIV has been highly successful over the past decade, and clinicians must remain vigilant in the diagnosis and treatment of HIV-infected pregnant women 1.

From the FDA Drug Label

8 USE IN SPECIFIC POPULATIONS 8. 1 Pregnancy Risk Summary Clinical data over several decades with valacyclovir and its metabolite, acyclovir, in pregnant women, have not identified a drug associated risk of major birth defects. There are insufficient data on the use of valacyclovir regarding miscarriage or adverse maternal or fetal outcomes (see Data) There are risks to the fetus associated with untreated herpes simplex during pregnancy (see Clinical Considerations)

Disease-Associated Maternal and/or Embryo/Fetal Risk: The risk of neonatal HSV infection varies from 30% to 50% for genital HSV acquired in late pregnancy (third trimester), whereas with HSV acquisition in early pregnancy, the risk of neonatal infection is about 1%

Co-infection with HSV increases the risk of perinatal HIV transmission in women who had a clinical diagnosis of genital herpes during pregnancy.

The risks or complications that can play a role in issues with birth or new pregnancy in this scenario include:

• Neonatal HSV infection: The risk varies from 30% to 50% for genital HSV acquired in late pregnancy, and about 1% with HSV acquisition in early pregnancy.
• Perinatal HIV transmission: Co-infection with HSV increases this risk in women with a clinical diagnosis of genital herpes during pregnancy.
• Untreated herpes simplex during pregnancy: This poses risks to the fetus, including neonatal chorioretinitis, microcephaly, and skin lesions.
• Prior history of drug use: Although both individuals are currently sober, a history of drug use may still pose risks to the pregnancy. However, it is essential to note that the husband's use of HIV PrEP and his negative HIV status, but positive for HSV-2, are crucial factors. The wife's age (27 years old) and prior history of drug use are also important considerations. The FDA drug label does not provide direct information on the interaction between HIV PrEP and valacyclovir or the specific risks associated with this combination in pregnancy 2.

From the Research

Risks and Complications

• The husband's current use of HIV PrEP (pre-exposure prophylaxis) may reduce the risk of HIV transmission, but its effectiveness in preventing other sexually transmitted infections (STIs) like HSV-2 is still being studied 3.
• The study found that daily oral PrEP using tenofovir disoproxil fumarate (TDF) alone or in combination with emtricitabine (FTC-TDF) reduced the risk of HSV-2 acquisition among heterosexual men and women 3.
• However, the husband's positive status for HSV-2, although in remission, may still pose a risk of transmission to the wife, especially if he experiences an outbreak during pregnancy.
• The wife's prior history of drug use may also increase the risk of complications during pregnancy, such as premature birth or low birth weight.

Pregnancy Considerations

• Unplanned pregnancy in a 27-year-old woman with a prior history of drug use may increase the risk of complications during pregnancy 4.
• The use of PrEP during pregnancy has been shown to be safe and effective in preventing HIV transmission, but its use in women with a history of drug use requires careful monitoring and management 5.
• The couple's current sobriety is a positive factor, but ongoing support and monitoring may be necessary to ensure a healthy pregnancy and prevent relapse.

HIV PrEP and Pregnancy

• The US Preventive Services Task Force recommends offering PrEP to persons at high risk of HIV acquisition, including those with a history of drug use 4.
• Studies have shown that PrEP is effective in preventing HIV transmission among high-risk individuals, including those with a history of drug use 5, 6.
• However, the use of PrEP during pregnancy requires careful consideration of the potential risks and benefits, and ongoing monitoring and management to ensure a healthy pregnancy and prevent HIV transmission.

HSV-2 and Pregnancy

• The husband's positive status for HSV-2 may increase the risk of transmission to the wife during pregnancy, especially if he experiences an outbreak 3, 7.
• Valacyclovir may be used to reduce the risk of HSV-2 transmission, but its effectiveness in preventing HIV transmission is still being studied 7.
• The couple should discuss the risks and benefits of valacyclovir use during pregnancy with their healthcare provider and take steps to prevent HSV-2 transmission, such as using condoms and avoiding sexual contact during outbreaks.