There are a couple of options—some hi-tech expensive and not available in Malawi and some full proof and some a bit controversial and risky.
Spermwashing, for instance, involves removing the seminal fluid surrounding a sperm, and then implanting that sperm in one of the female’s eggs. HIV is carried by seminal fluid, but not by the sperm itself. Recent research shows spermwashing to be safe, if done by qualified medical personnel.
Spermwashing is approved by the World Health Organisation (WHO), however, the United States (US) Centers for Disease Control and Prevention (CDC) recommends against it as an option due to at least one documented case in which a female partner became infected with HIV via spermwashing. To my knowledge spermwashing is not available in Malawi.
Use of pre-exposure prophylaxis (PrEP) prior to conception can greatly reduce a female’s risk of contracting HIV. PrEP is the procedure of taking anti-retroviral medications, if you are HIV-negative, to prevent you from acquiring the disease.
More controversial option, is for an HIV positive man to use HIV treatment to reduce his viral load to undetectable levels both in blood and semen, and then to use limited conception attempts at the most fertile days in the woman’s cycle. Conception can either be naturally—having gentle sex—or using self insemination. Most doctors can provide guidance on how to plan and identify which days would be appropriate.
Viral load in semen can be tested using the same viral load tests that are used for blood, and your hospital could advise on this. The additional safety from testing semen viral load is that approximately 10 percent of people with undetectable levels in blood, can have detectable levels in semen.
Artificial or self-insemination would reduce the risk of trauma during sex where a small tear could increase the risk of HIV transmission.
This is more controversial because there is a small risk of transmitting HIV. However, especially where spermwashing is not available, there have been encouraging reports that this has been successful—in one report around 60 couples conceived without any HIV transmission. For many women who want to have children, this risk may be acceptable, but it can only be something that the woman decides freely.
Another option is conception with an HIV-negative sperm donor or sexual partner via sexual intercourse or artificial insemination — sperm banks test all donor sperm for HIV. But I don’t think there are sperm banks in Malawi. Or foster or adopt a child. And remember continuing to use condoms at all other times is essential. n