When Susan Hartmann got married, she and her husband knew that they had to be careful. Given that she's HIV-negative and he's HIV-positive, they had to be vigilant about protected sex. But later, they decided they wanted to start a family.
After hearing about high-tech assisted reproduction techniques that could help them conceive safely, they sought advice from the perinatal HIV clinic at the University of California at San Francisco. But the doctors presented an option they hadn't considered: They could do it the old-fashioned way, by having unprotected sex.
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Hartmann was floored by the suggestion.
"It was counter to decades of public health messaging," she said.
She and her husband, Dan, looked at the research. Numerous studies supported the idea that her risk of infection was extremely low because his viral load was undetectable and they would be having unprotected sex only a few times, when she was ovulating.
The couple decided to go for it, and the happy result was a little girl they named Ryan. Both mother and daughter are HIV-negative.
More than 1.1 million Americans -- about three-fourths of them men and one-fourth women -- are infected with HIV, and as they are living longer, healthier lives thanks to advances in antiretroviral therapy, a growing number have expressed the desire to start a family.
Couples in which one or both partners are HIV-positive have been using adoption, surrogacy or donor eggs or sperm for years, but those avenues are often incredibly expensive. Today, some doctors are endorsing intercourse without a condom as another option. It allows couples to have biological children and it's free. Medical professionals are backed by a new understanding about the mechanisms of HIV transmission and the development of a fantastically effective once-a-day pill taken by the HIV-negative partner that can reduce the risk of infection.
And a baby born to an HIV-positive mother, regardless of the father's status, now has a less than 1 percent chance of getting the virus, with proper treatment.
"We have gone from a story of risk reduction to one of possibility," said Shannon Weber, coordinator for the Bay Area Perinatal AIDS Center in San Francisco, which in 2012 started a program to help HIV-positive men with HIV-negative women -- the most complicated situation to deal with from a medical standpoint -- have children.
"We have done such a disservice to them over the years," Weber said. "They have had very little information about safe conception, and for many of them this is the first time they were asked whether or not they wanted to have a family."
New studies have consistently shown that intercourse without a condom with someone who is HIV positive may not be as risky as people once thought if the infected person's viral load is low and the person takes medication regularly, according to Mark Saur, vice chairman of the obstetrics and gynecology department at the Columbia University Medical Center. A study of 750 mixed-status heterosexual and gay couples presented this year at a conference in Boston found no cases of linked HIV transmission when the positive partner was on antiretroviral therapy.
Saur said his practice plans to begin counseling mixed-status couples about the reproductive option later this year and will require the HIV-negative mother to take an anti-viral medication approved by the Food and Drug Administration in 2012 for lowering the risk of infection even further in such cases.
"Like all innovative therapies, there's not a lot of data yet, but everything we do know points to this being a reasonable risk," he said.
Erika Aaron, an assistant professor at Drexel University's College of Medicine, has helped five HIV-negative women with HIV-positive partners get pregnant via intercourse while on anti-retrovirals over the past year and a half. None have become infected with HIV. She said that when she started talking about this option "it was hard to get the words out of my mouth" because she had been telling people the opposite for so many years.
But, Aaron said, "now that we know ways we can minimize transmission by ways other than using condoms, it's important that we let them know this is an option."
The view isn't universally accepted.
Some primary-care physicians say they are uncomfortable with the approach because the risk of transmission, however small, still exists and it is their responsibility to do no harm. And some of those in the public health arena, especially those who have been fighting the epidemic for decades, say they worry that the research could be used to justify reckless behavior that could undo years of safe-sex advocacy.
Michael Weinstein, president of the Los-Angeles based AIDS Healthcare Foundation, said that the research about unprotected sex as a means of conception is promising, but that the practice cannot be guaranteed to work in the real world. He said that HIV viral loads fluctuate and that even the most well-intentioned would-be mothers and fathers could forget to take their medication. He said that if there happens to be a spike in a man's viral load while a couple is trying to conceive, the risk to the woman would increase dramatically.
"People are going to make whatever decision about risk with their doctors," Weinstein said. "But as a public health person, I cannot advocate this."
Mixed HIV status, or serodiscordant, couples looking to start a family have a menu of options in addition to the traditional routes of adoption, surrogates, and egg or sperm donors.
If it is the woman who is HIV-positive, artificial insemination with a syringe is practical, cheap and effective, but things are more complicated if it is the man who is HIV-positive.
Using "washed" sperm that is treated to reduce or eliminate infectious material in the semen being transferred to a woman is one option. While sperm washing is a popular method in other countries, the U.S. Centers for Disease Control and Prevention has recommended against the practice, saying it does not always eliminate the virus. As a result, advocates say, few clinics offer this service -- - making it a more expensive and time-consuming option than it might otherwise be.
For couples considering intercourse, doctors are conflicted over whether using drugs such as Truvada for pre-exposure prophylaxis, or PrEP, can provide another layer of protection for the mother.
The drug, in the form of a blue pill, is supposed to be taken once a day for 365 days and costs $12,000 to $16,000 a year, most of which is covered by insurance.
There have been no studies on how Truvada or other anti-retrovirals should be given to HIV-negative women seeking to conceive with their HIV-positive partners. Some doctors prescribe it for use only on days when the couple has intercourse, while others tell patients to take it continuously for months or even years while they are trying to conceive.
Others say that the potential side effects and risks may not be worth it for those whose partners have their viral loads under control, so they don't prescribe it. Truvada is known to cause nausea and vomiting and has been linked to kidney issues. Some epidemiologists have expressed concern about the theoretical possibility that if the drug is used irregularly and widely it could lead to creation of a superstrain of Truvada-resistant virus.
Caroline Watson, a 25-year-old from San Francisco who is HIV-negative and whose husband, Deon, 33, is HIV-positive, conceived a child through intercourse, but she declined to take Truvada or another antiretroviral because of the possible risks. Neither she nor her daughter, Valerie, who celebrated her first birthday in February, were infected.
"Some of my friends told me I was crazy, that I was being stupid," Watson said. "But the science supports what I did."
The Hartmanns went to high school together in Annapolis, Md., and were good friends. Dan, who suffers from hemophilia, a disorder in which the blood does not clot properly, had been infected with HIV through a transfusion when he was 12. Susan knew about his HIV status, but it did not make a difference to her then or when they reconnected years later and fell in love.
It became an issue only when they decided to start a family, a year after they were married and living in Northern California. She was the program manager for the University of California at Berkeley's Center for Cities and Schools, and he was a graphic artist working for the state.
The use of anti-retrovirals on HIV-negative women was not so common, and Hartmann said she decided not to take them. She became pregnant within two months.
"Had I rolled the dice and gotten HIV, it was a risk I was willing to take. We did what we could to minimize that outcome, but as an HIV-negative partner there is always a level of risk one takes," she said.
The Hartmanns, both 39, live in Odenton, Md., with their daughter, who is 4. They say they are thinking about having another child. If they do, they will probably go the same route.
"We did a lot of soul searching about how do we live lives that we want to live," Hartmann said. "My husband is not counting the days until he dies. He is expecting a long life, and we want a family."