HIV infection and procreation are no longer incompatible. In the era of highly active anti-retroviral therapy (HAART) and because of medical techniques, more available in developing countries, it is possible to considerably reduce the risk of transmission of HIV for couples who want to have children. It is possible to obtain sperm samples from HIV positive men that do not contain traces of the virus, and antiretroviral therapies lower the rate of transmission of HIV from mother to child.

Since May 2001, sero-different couples in France have the right to take advantage of medically assisted conception (MAC), which is also available for couples with fertility problems.
The choice of which MAC method to use is determined by the couple’s fertility assessment (gynecological and spermatological) and by the level of virus detected in the male partner’s seminal fluid. Intrauterine insemination (IUI) is suggested for more fertile couples and in vitro fertilization (IVF) or in vitro fertilization by microinjecting sperm is recommended for couples that are less fertile. In couples where the man is HIV positive (and not the woman), MAC is conducted with sperm that has been treated and a verification has been conducted to ensure that RNA HIV is nonexistent.
In fertile couples where the woman is HIV positive MAC is unnecessary. The couple can inseminate using sperm that has been placed in a sterile container, which is then injected deep into the vagina with a needleless syringe. This can be done at home or at a gynecologist’s office. 

Natural conception was debated at length throughout the four days. These debates were the reaction to the Swiss Federal Office of Public Health’s 2008 declaration which states that HIV positive people who have no other STIs besides HIV, who are efficiently responding to ARVs, have had an undetectable viral load for the last 6 months and are receiving quality medical care. Under these conditions, the Swiss authorities believe that people living with HIV will not transmit the virus through sex. One of the limits of this declaration is that there is a difference between blood plasma and seminal plasma in an HIV positive man’s body: an undetectable viral load in plasma is not therefore predictive of an undetectable viral load in seminal fluid. There is still a risk of HIV transmission even if treatment is effective. Measuring the seminal viral load should be offered to couples wishing to conceive naturally.

For couples that do not wish to use MAC, natural conception through unprotected sex during ovulation has for a long time been, and continues to be, a popular option. It requires a follow up by biological means and ultrasound. This method is not risk-free and goes against general HIV prevention recommendations.

What solutions are there for people in developing countries?
Very few experiences of medical care and the desire to have a child for PLWHAs in developing countries were presented at this conference. Nonetheless, it is important to address this desire, which concerns a growing number of couples. Gynecologists are increasingly faced with infertility among PLWHAs. Medically assisting procreation is therefore clearly an issue in African countries. But as MAC techniques are unavailable in most countries the options for PLWHAs remain limited. There is no magic formula. Couples living with HIV who want to start a family require support from an interdisciplinary team that includes doctors, biologists, psychosocial counselors, and psychologists.
To ensure that natural conception takes place with the lowest possible risk, there are two essential conditions: 1) an undetectable viral load and 2) an absence of STIs capable of increasing the transmission of HIV. In the case of HIV different couples where the man is HIV positive, awareness of the woman’s fertile phase will enable them to better time sexual relations. It is recommended that the HIV negative partner take ARVs in prophylaxis pre and post exposure.
It is important to address couples’ desire to create a family and to support them in this aspiration because the risk of having unprotected sex and consequently the risk of HIV transmission is high.

We are conducting a quality survey among our partners to evaluate the Growing Up program’s publications and tools. These partners include: KidAIDS, SWAA-Littoral, and WESDE in Cameroon, Avenir Positif and Serment Universel in the Congo Brazzaville, RACINES and CCSA in Benin, REVS+ in Burkina-Faso, CSAS in Côte d’Ivoire,  ARCAD/sida and AKS in Mali, ADN in Chad, as well as AMC and EVT in Togo. This survey aims to measure how much Growing Up’s information platforms and teaching tools are used as well as how satisfied their users are. The results will be presented in an upcoming issue of Growing Up Info.

For World AIDS Orphans Day (May 7th) Growing Up would like to highlight N’ZRAMA’s recently completed study on HIV disclosure to family members.

N’ZRAMA is an organization created in 2000, comprised of HIV infected or affected children and young people in Bouaké (Côte d’Ivoire), who are members of families who are followed at the Centre Solidarité Action Sociale (C.S.A.S). Refusing fatalism, these young people decided to leave behind the status of victim to become protagonists. N’ZRAMA’s main mission is to help improve the conditions of life of children and young people affected by HIV. This includes home or hospital visits, support groups, medical support, hygiene counseling, nutritional support, strengthening organizational links and lobbying activities.
In December 2008, N’ZRAMA conducted a study of households who benefit from their services. The subject of the study was HIV disclosure to family members. 71 people participated anonymously in the study.
The study showed that 80.3% of PLWHAs told someone close to them that they were living with HIV: 46.4% told an immediate family member (father/mother, brother/sister), 18.3% told their husbands/wives/partners, in-laws, 2.8% told a friend/acquaintance (friend, neighbor, priest/pastor/imam, colleague) and 28.3% told their children (biological or adopted); in this last group the person generally told older children (18 and older) and those who no longer lived in the same household at the time the study was conducted.

In addition, this study showed that 47 PLWHAs (66.2 %) rarely or never spoke to their children about subjects like HIV/AIDS or sexuality, for fear of upsetting the children and broaching inappropriate subjects.

This study, conducted in Bouake, illustrates the inadequate level of communication in many PLWHA families. It is important to encourage developing dialogue between parents and children and within couples.

We want to support our African partners who are launching an HIV screening campaign for fathers by conducting this contest among our readers! The picture you see here was drawn by our illustrator, Picha Masma, and will figure on the campaign’s poster. The idea is to inform men of the importance of testing in general, as well as during the course of their wives pregnancies: “Men should know their status too-- not just women!”
Now it’s your turn to imagine what these men are saying to each other and to come up with a slogan for the poster: a pertinent message that will encourage fathers to take an HIV test. 

Send in your suggestions to: grandir@sidaction.org

Mariam is 23 years old and pregnant for the first time. She lives in a village around 30 km from your health center. She has been referred to you by the regional hospital after testing positive for HIV. Her CD4 count which is 200/mm3, was done 4 months ago. She is 36 weeks pregnant. Mariam has come with her mother in law and she doesn’t seem to understand what is going on. She is exhausted. During the course of your conversation with Mariam, you learn that she is the 2nd wife in the household and her only income is her husband’s. What role will your staff play in accompanying this young woman?

We suggest the following:
Mariam’s situation is critical and emergency measures must be taken in priority. Refer Mariam to the organization’s doctor who will decide whether or not she should be checked into the hospital. 
Set up an appointment to talk to her alone in a safe, confidential environment once she has recovered, to review her circumstances with her:
­-What does she know about HIV and what has she understood about her own status (repeat the post-test counseling);
­-Why she came here (late);
­-Pregnancy care and follow up (antenatal consultations, birth planning: counsel her to give birth in a maternity ward that ensures PMTCT services by explaining the implications for the baby);
­-ARV therapy: Since Mariam was referred by a regional hospital it is important to conduct a recapitulation of the medical care she received there. Mariam’s CD4 count indicates that she is eligible for ARV treatment to prevent transmission of HIV to her baby. Check if she has already received ARV treatment. If she has, it is crucial to reiterate the importance of correctly taking her ARVs. During this review misunderstandings can be corrected.  If she has not received ARV therapy before, Mariam should start treatment immediately. If she can not obtain ARV treatment with your organization, she should be referred to another centre.

Feeding the newborn baby: You need to have a conversation with Mariam about different infant feeding options while explaining the advantages and disadvantages of each one. Encourage Mariam to think this through.  There is little chance that you will have the opportunity to see Mariam again before she gives birth as her pregnancy is close to term. Now it is important to schedule a home visit with her or if possible, an appointment at the office, to review everything one more time before her baby is born. 
The pre-natal appointment will be an opportunity to go over the following points:  the place where the baby will be born and the treatment that s/he will receive (infant feeding, early testing, medical and nutritional follow-up), telling her partner about her HIV status, her own care (medical care, adherence, contraception).
Suggest that she join a pregnant women or mothers’ support group if your organization has one and explain why this can be helpful to her. Before she leaves you can offer to talk to her mother-in-law to explain that her daughter-in-law’s condition means that it is best if she gives birth in a health center (without necessarily specifying why).

Mariam needs to contact the appropriate social service to ensure that she has the necassary support (transport reimbursement, nutritional support, and so on).