What are the recommendations for a female trying to get pregnant with a partner who is HIV (Human Immunodeficiency Virus) negative and virally suppressed on abacavir (Ziagen), dolutegravir (Tivicay), and lamivudine (Epivir)?

Recommendation for Female Trying to Conceive with HIV-Positive Partner on Abacavir/Dolutegravir/Lamivudine

If the HIV-positive partner is virally suppressed on abacavir/dolutegravir/lamivudine, the female partner can safely attempt conception through unprotected intercourse without risk of HIV transmission, and no changes to the partner's antiretroviral regimen are needed for conception purposes. 1

Key Principle: Undetectable = Untransmittable (U=U)

• Viral suppression eliminates sexual transmission risk. When an HIV-positive individual maintains an undetectable viral load (typically <200 copies/mL), there is effectively zero risk of sexual transmission to an HIV-negative partner. 1

• The partner's current regimen of abacavir/dolutegravir/lamivudine is highly effective for maintaining viral suppression and does not require modification for conception attempts. 1

Preconception Counseling for the Female Partner

Confirm Partner's Viral Suppression Status

• Verify that the HIV-positive partner has documented viral suppression (HIV RNA <200 copies/mL) on at least two consecutive measurements over the past 6 months. 1

• Ensure adherence to antiretroviral therapy is excellent, as this maintains viral suppression and eliminates transmission risk. 1

Folate Supplementation

• The female partner should begin folate supplementation (at least 400-800 mcg daily) before attempting conception to reduce the risk of neural tube defects, which is standard preconception care for all women. 1, 2

Timing of Conception Attempts

• Unprotected intercourse can occur during the female partner's fertile window without additional precautions once viral suppression is confirmed. 1

• No assisted reproductive technologies (such as sperm washing) are necessary when the HIV-positive partner is virally suppressed. 1

Considerations Regarding the Partner's Dolutegravir-Based Regimen

Neural Tube Defect Risk Context

• The neural tube defect concern applies to the pregnant person taking dolutegravir, not to conception with a partner taking dolutegravir. The FDA label and guidelines specifically address risk when dolutegravir is taken by the person who becomes pregnant at the time of conception through the first trimester. 2, 1

• Updated surveillance data from Botswana (>14,000 exposures) show the initial neural tube defect signal has diminished and is no longer statistically significant compared to other antiretroviral regimens. 1, 3

• Since the female partner in this scenario is HIV-negative, she will not be taking dolutegravir, so this concern does not apply to her pregnancy. 2

Partner's Regimen Stability

• The HIV-positive partner should continue their current abacavir/dolutegravir/lamivudine regimen without interruption during conception attempts and throughout the partner's pregnancy. 1

• Switching the partner's regimen is unnecessary and could risk loss of viral suppression, which would increase transmission risk. 1

Monitoring During Conception Attempts

• The HIV-positive partner should maintain regular HIV care with viral load monitoring every 3-6 months to ensure continued suppression. 1

• The female partner should undergo standard preconception and prenatal care, including HIV testing at the first prenatal visit to confirm HIV-negative status. 1

Common Pitfalls to Avoid

• Do not recommend condom use or timed intercourse methods (such as limiting intercourse to ovulation only) when the HIV-positive partner is virally suppressed, as these create unnecessary barriers to conception without providing additional protection. 1

• Do not switch the HIV-positive partner's antiretroviral regimen based on concerns about dolutegravir and neural tube defects, as this risk only applies to the pregnant person taking dolutegravir, not their partner. 2, 1

• Do not delay conception attempts while waiting for "safer" antiretroviral options for the partner, as the current regimen is highly effective and the U=U principle is well-established. 1

• Do not recommend sperm washing or other assisted reproductive technologies solely based on HIV status when viral suppression is documented, as these interventions are unnecessary and add cost and complexity. 1

If the Female Partner Becomes HIV-Positive

• If the female partner tests HIV-positive during pregnancy (which would be extremely unlikely with a virally suppressed partner), immediate initiation of antiretroviral therapy is indicated. 1

• The recommended regimen for a newly diagnosed pregnant person would be dolutegravir plus tenofovir alafenamide/emtricitabine (or tenofovir disoproxil fumarate/emtricitabine if tenofovir alafenamide is unavailable), as this provides optimal virologic suppression with low rates of adverse birth outcomes. 1