U=U should mean reproductive freedom — but many fertility clinics haven’t caught up yet
Someone living with HIV calls a fertility clinic to ask about booking a consultation. They may have spent months planning for this moment, choosing the right time, the right support, the right words. But instead of a clear pathway to care, they are told that they need to be referred somewhere else. Or that the clinic is “not sure” whether they can provide services. Or they are met with silence on the phone while someone tries to decide how to respond.
For many people living with HIV who want to build families, this is still a familiar experience.
For people living with HIV in Canada, parenting and pregnancy planning should be a supported and affirming part of healthcare. The evidence is clear. When a person living with HIV is on antiretroviral treatment and has a sustained suppressed viral load, HIV is not transmitted to a sexual partner. With appropriate perinatal care, the likelihood of HIV transmission during pregnancy and birth is zero. Canadian surveillance data shows perinatal transmission rates of 0.6% or less, with most provinces reporting no transmissions for decades. These outcomes reflect vast progress and are consistent with national and international guidance recommending full reproductive choice and pregnancy support for people living with HIV.
Yet reproductive autonomy is still inconsistent across the country. Many people who want to plan a pregnancy encounter hesitation, delays or policies that have not caught up with the science. These barriers are not simply misunderstandings in individual clinical encounters. They reflect deeper structures and systems that have failed to evolve at the same speed as the evidence.
We recently conducted a national survey of fertility clinics to understand how care is currently being offered. The results show progress — but also persistent gaps that continue to limit reproductive autonomy for people living with HIV.
What fertility clinics are doing now
In 2023, just over 50% of responding clinics reported that they would provide consultation to people living with HIV. This represents a decline in access compared to a similar survey in 2014, when nearly all clinics surveyed accepted referrals. Also, across Canada, access to assisted reproduction varied significantly. Many clinics offered only intrauterine insemination (IUI), and only four provinces had at least one clinic that provided in vitro fertilization (IVF).
The availability of assisted reproduction also depends on viral suppression. Most clinics that saw patients living with HIV offered IUI or IVF when the viral load was undetectable. Very few offered assisted reproduction when the viral load was detectable. Again, access to these services remains concentrated in only a few provinces and only in major cities.
Knowledge and use of the Canadian HIV Pregnancy Planning Guidelines was also limited among respondents. Some providers were familiar with the guidelines and used them; others had heard of them but had not incorporated them into practice; and some were unaware of them entirely. Together, these findings show that reproductive care for people living with HIV in Canada is shaped by clinic policy, provider comfort and geography — not just medical evidence or patient readiness.
What U=U means for pregnancy planning
U=U, undetectable equals untransmittable, has fundamentally changed what safe, supported pregnancy planning looks like. When viral load is undetectable, HIV is not transmitted through sexual activity. And when someone is undetectable prior to conception and supported in maintaining viral suppression throughout pregnancy, the chance of HIV being passed to an infant is zero. For people planning a pregnancy, this means that condomless sex to conceive is safe when viral load is undetectable, and that pregnancy and birth can proceed without the risk of HIV transmission.
Current Canadian practice supports shared decision-making around infant feeding when viral load is suppressed, ensuring that parents living with HIV who choose to breastfeed receive informed, non-judgmental clinical support. At the same time, it acknowledges that—while the risk is extremely low—the possibility of HIV transmission through breastfeeding cannot be confirmed to be zero.
U=U has not only been proven scientifically, it is also a message about safety, trust and belonging. It communicates that people living with HIV can form relationships, build families and experience intimacy without fear. When healthcare systems fail to reflect U=U consistently, the message that reaches patients can feel mixed or conditional. This inconsistency undermines both reproductive autonomy and emotional well-being.
Why this is a matter of equity
Stigma surrounding pregnancy and HIV does not affect everyone in the same way. Women, trans and nonbinary people living with HIV often navigate multiple layers of discrimination, including racism, colonialism, transphobia and sexism in addition to HIV-related stigma. For many, the possibility of being dismissed or judged when discussing pregnancy is not theoretical; it is lived experience. If a fertility clinic responds with hesitation or redirects care, the impact is not simply inconvenience. It can feel like a denial of person-centred care. Reproductive autonomy is not just the ability to become pregnant. It is the ability to make decisions about one’s body and family.
Where we can go from here
The encouraging part of our findings is that fertility providers are not resistant to change. Many are motivated to improve care and want clearer guidance, training and policy frameworks that support inclusion rather than caution. The science is there. The guidance is there. The lived expertise of women and nonbinary people living with HIV is there. The work now is to ensure our systems catch up.
We must ensure that pregnancy planning is discussed routinely in HIV care, that fertility clinics adopt and update policies informed by U=U, and that care environments reflect respect for the lives and families of people living with HIV. Above all, it means centring the leadership of people living with HIV in designing and evaluating reproductive care. Clinicians and service providers can take a five-part free accredited online course based on the 2018 Canadian HIV Pregnancy Planning Guidelines. This self-directed offering has been designed specifically for providers to learn how to counsel on essential reproductive health information in the context of HIV.
We know that pregnancy is safe when viral suppression is sustained. We know that people living with HIV are parents and caregivers in every community. Now we need healthcare systems to support their right to pursue parenthood without unnecessary barriers. Let’s make it happen—take the online course.
Dr. Mona Loutfy is an infectious diseases specialist, clinician scientist and full professor at the University of Toronto and Women’s College Hospital in Toronto. Her main clinical practice is at the Maple Leaf Medical Clinic where she specializes in care of women, gender diverse people, youth and couples with HIV and reproductive health and HIV. She founded the Women HIV and Health Research Program at the Women’s College Research Institute in 2006 to carry out research with and for women living with HIV to combat stigma and health inequity and optimize health care delivery and outcomes.
Amy Ly is a research coordinator with the Women HIV and Health Research Program. She holds a master of science from the University of Toronto and has four years of experience leading HIV/STBBI research and community-based health systems projects. Her work focuses on scaling women-centred HIV care models, strengthening patient-provider communication and advancing equity in health services.