For couples where one partner has HIV, conceiving the usual way is now a guideline-supported option. U.S. perinatal HIV guidelines say that when the partner with HIV takes antiretroviral therapy and has sustained viral suppression, condomless sex for conception does not transmit HIV to the partner without HIV. PrEP for the HIV-negative partner is an optional extra layer, and recommended if suppression is not confirmed. Sperm washing is no longer routinely recommended.
It starts with the viral load
What has changed — and why it matters
If you looked into this topic years ago, you may remember advice built around sperm washing, timed condomless sex only under strict conditions, and a lot of fear. The science has moved. The U.S. Department of Health and Human Services (HHS) Perinatal HIV Clinical Guidelines, last updated in January 2024, now describe a much simpler foundation: effective HIV treatment for the partner who has HIV, with PrEP as an added option for the partner who does not.
The guidelines say plainly that sperm preparation techniques such as sperm washing are no longer routinely recommended, because they were largely developed before studies demonstrated how well antiretroviral therapy (ART) and PrEP prevent transmission. Washing still has niche uses, but it is no longer the gatekeeper to parenthood.
This article covers couples where one partner has HIV. It applies whether the partner with HIV is the one who would carry the pregnancy or the one providing sperm, and the same principles inform couples using a gestational carrier.
What “undetectable” means for conception
The CDC defines viral suppression as having fewer than 200 copies of HIV per milliliter of blood, and states that a person who takes HIV medicine as prescribed and stays suppressed “will not transmit HIV to their sex partners.” This is the basis of the phrase undetectable = untransmittable, or U=U.
For conception specifically, the HHS guidelines set a slightly more careful bar before trying: sustained viral suppression, shown by two viral load results below the limit of detection taken at least three months apart (a strong recommendation). Once that is in place, the guidelines say condomless sex for conception does not transmit HIV to the partner without HIV.
Undetectable does not prevent other sexually transmitted infections, which is one reason STI screening is part of the plan (more below).
PrEP for the HIV-negative partner
Pre-exposure prophylaxis is medication the HIV-negative partner takes to prevent acquiring HIV. The HHS guidelines say:
- Clinicians should discuss PrEP with all sexually active people without HIV, including people trying to conceive, covering benefits and possible side effects during conception, pregnancy, postpartum, and breastfeeding.
- PrEP is recommended when the partner with HIV has not reached sustained suppression or their status is unknown.
- PrEP is an option even when the partner with HIV is suppressed. Some couples choose it for peace of mind while trying.
Not all PrEP is the same for this purpose. When PrEP is indicated and pregnancy is planned, the panel recommends TDF/FTC whenever possible and notes it is FDA-approved as PrEP for all populations. It also notes that TAF/FTC is not approved for preventing HIV acquired through receptive vaginal sex, and that safety and pharmacokinetic data for long-acting injectable cabotegravir are limited for people planning pregnancy. Ask your prescriber which option fits your situation, and how consistently it must be taken to work.
If you are not sure where to get PrEP, FreePrEP.org is a free guide to finding PrEP and low-cost access options.
Your options, depending on who has HIV
| Situation | Paths the HHS guidelines describe |
|---|---|
| The partner providing sperm has HIV | Condomless sex timed to the fertile window once sustained suppression is confirmed; PrEP for the partner who will carry the pregnancy (recommended if suppression is not confirmed, optional if it is); donor sperm from a donor without HIV is another option. |
| The partner who will carry the pregnancy has HIV | Condomless sex with sustained suppression; or insemination with the partner’s semen around ovulation, which removes any transmission risk to the sperm-providing partner. PrEP for the HIV-negative partner remains an option. |
| Both partners have HIV | Both should be on ART with sustained suppression before trying. |
| Infertility, donor sperm, or a gestational carrier | Assisted reproduction (IUI or IVF) remains useful for these situations, just as for any couple. |
Timing sex or insemination to the fertile window keeps the number of attempts focused. If you are using home insemination, ask your clinician about safe technique and supplies.
For same-sex couples and anyone building a family with donor sperm or a gestational carrier, our sister site’s guide to LGBTQ+ fertility options covers the logistics.
STI screening and the rest of preconception care
The HHS guidelines recommend that both partners be screened for genital tract infections before trying to conceive, and treated if needed, with rescreening considered based on individual risk. They note that STIs do not raise the risk of HIV transmission when the partner with HIV is suppressed on ART or when PrEP is used — but screening still matters for both partners’ health and for pregnancy outcomes.
Everything else on a standard preconception list applies too: folic acid, vaccines, a review of other medications, and general health. Our TTC checklist covers those steps. If the partner with HIV will carry the pregnancy, it is also worth asking their HIV clinician whether their current ART regimen is the one they would want during pregnancy, so any change happens before conception.
- Do my last two viral loads meet the bar for sustained suppression?
- How often should we check viral load while we are trying?
- Is my current regimen the one you would recommend during pregnancy?
- Should my partner take PrEP, and which kind?
- When should we be referred for an infertility evaluation if it is taking a while?
Pregnancy, birth, and feeding when the pregnant partner has HIV
When the person carrying the pregnancy has HIV, the focus shifts to preventing perinatal transmission. The CDC reports that the risk of transmission during pregnancy, labor, and delivery is 1% or less when HIV medicine is taken as prescribed throughout pregnancy and delivery and the baby receives medicine for 2–6 weeks after birth.
Feeding is a more individual conversation. The CDC describes the risk through breastfeeding with an undetectable viral load as less than 1%, but not zero, and asks providers to discuss options with people who want to breastfeed. It is worth raising early in pregnancy so you have time to decide.
If it is taking a while
HIV does not change the basic biology of conception. The HHS guidelines recommend an infertility evaluation, including semen analysis, if pregnancy has not happened after 12 months of trying — or sooner depending on age or other factors. Our guide on when to see a fertility specialist explains the usual timelines.
The human side: fear, stigma, and talking about it
Many serodifferent couples carry years of messaging that sex is dangerous, and that can be hard to set down even when the science says otherwise. A few things that help:
- Go to at least one appointment together. Hearing the viral load results and the plan from the same clinician removes a lot of second-guessing.
- Decide on PrEP as a couple. It is optional when suppression is confirmed, and some partners simply sleep better with it. That is a valid reason.
- Find a clinician who is comfortable with this. The HHS guidelines recommend expert consultation to tailor care. If your provider seems unfamiliar with current guidance, it is fine to ask for a referral.
- Disclosure to family is your call. Your health information belongs to you. Prenatal care does not require telling anyone outside your care team.
Frequently asked questions
Can we conceive naturally if one partner has HIV?
Yes, under the right conditions. U.S. perinatal HIV guidelines say that when the partner with HIV is on antiretroviral therapy with sustained viral suppression, condomless sex for conception does not transmit HIV to the partner without HIV.
What counts as sustained viral suppression before trying to conceive?
The HHS perinatal guidelines define it as two viral load results below the limit of detection at least three months apart before attempting conception.
Does the HIV-negative partner need PrEP while trying to conceive?
PrEP is recommended if the partner with HIV is not yet virally suppressed or their status is unknown, and it is optional when suppression is confirmed. The guidelines prefer TDF/FTC when PrEP is used while planning pregnancy.
Is sperm washing still necessary?
Usually not. The HHS guidelines say sperm washing is no longer routinely recommended because effective HIV treatment and PrEP prevent transmission. Assisted reproduction is still used for infertility, donor sperm, or gestational carriers.
What is the risk of passing HIV to the baby?
The CDC reports the risk during pregnancy, labor, and delivery is 1% or less when HIV medicine is taken as prescribed throughout pregnancy and delivery and the baby receives medicine for 2 to 6 weeks after birth.
Sources & guidance
- HHS Perinatal HIV Clinical Guidelines: Prepregnancy Counseling and Care — Reproductive Options When One or Both Partners Have HIV (updated January 31, 2024)
- CDC: HIV Treatment as Prevention
- FreePrEP.org: PrEP access guide