Introduction to HIV Discordant CoupleInsemination

Deborah J. Anderson, Ph.D.

Dept Medicine and Center for AIDS ResearchHarvard Medical School and

Department of Obstetrics & Gynecology Boston University School of Medicine

Boston, MA

1987

• HIV/AIDS: a poorly understood lethal sexually transmitted disease

• Stewart et. (1985): seroconversion in 4 women following AI with semen from an HIV+ donor

• Published reports of HIV attachment to sperm

• High fetal maternal transmission rate

Dr. Enrico Semprini proposed to establish a protocol to reduce the risk

of HIV transmission in HIV-1 discordant couples desiring a child

Gradient Sperm Separation Method

Seminal Plasma

47% Separation Medium

90% Separation Medium

Motile Sperm

Nonmotile Sperm,Immature Germ CellsWBCs

DiscontinuousDensity Gradient

HIV p24

++++

++

++

+/-

Swim-up Method

Sw

im-u

p

Motile Sperm for Insemination

Sperm Wash Medium

Swim-up

HIV p24

+/-

++

Gradient/Swim-up Method

Sw

im-u

p

Wash Pellet

Seminal Plasma

47% Separation Medium

90% Separation Medium

Motile Sperm

Nonmotile Sperm,Immature Germ CellsWBCs

HIV p24

undetectable

Additional elements in Semprini protocol:

• Reduce exposure by maximizing fertility and optimal timing of fertilization

• Reduce transmission risk by treating STDs and reducing HIV viral load

1990

Chiasson MA, Stoneburner RL, et al. Human Immunodeficiency Type 1 virus transmission through artificial insemination. JAIDS 3:69-72, 1990

131 women in New York inseminated with fresh semen from 6 HIV+ donors. One seroconverted.

Centers for Disease Control.

HIV-1 infection and artificial insemination with processed sperm.

MMWR 39: 249-56, 1990.

Recommendation: Do not used processed semen from HIV+ donors for artificial insemination

1990

Semprini AE, Levi-Setti P, Bozzo M, Ravizza M, Pardi G.

Insemination of HIV-negative women with processed semen of HIV-positive partners.

Lancet 340:1317-9, 1992.

1992

1993

American Society for Reproductive Medicine Guidelines: ART services should be withheld from HIV-infected individuals or couples.

Fertility and Sterility 59 (Suppl 1): 1-39, 1993.

1997

Mandelbrot L, Heard I, et al. Natural conception in HIV-negative women with HIV infected partners. Lancet 349:850-1; 1997.

5% seroconversion rate in 92 HIV-discordant couples that practiced unprotected intercourse to conceive a child.

1998

Marina S, et al.

Human immunodeficiency virus type-1 serodiscordant couples can bear healthy children after undergoing intrauterine insemination .

Fertil. Steril. 70: 35-39, 1998.

2000

CreaThe is established: a consortium of 11 clinics in Europe that provide assisted reproductive technology services to HIV-1 infected couples.

•Forum for discussion

•Guidelines and protocols

•European database

2002

Antiretroviral therapy has changed the perception of HIV-1 disease (chronic but manageable) and reduced the maternal-fetal transmission rate to <5%.

HIV-1 infected individuals protected against medical discrimination by the Americans with disability act.

2002

Recommendations of the ASRM Ethics Committee on Human Immunodeficiency Virus and Infertility Treatment.

Fertility and Sterility 77: 218-222, 2002.

Fertility services cannot be reasonably withheld from individuals with chronic viral infections including HIV-1.

Sauer MV.

Providing fertility care to those with HIV: time to re-examine healthcare policy.

AJOB 2003; 3: 3-40.

ICSI procedure for insemination with HIV+ sperm

US Experience

00002-E-4 – 1 December 2002

Adults and children estimated to be living Adults and children estimated to be living with HIV/AIDS as of end 2002with HIV/AIDS as of end 2002

Total: 42 million

Western Europe570 000570 000

North Africa& Middle East

550 000550 000Sub-Saharan

Africa29.4 million29.4 million

Eastern Europe & Central Asia

1.2 million1.2 million

South & South-East Asia

6 million6 million

Australia & New Zealand

15 00015 000

North America980 000980 000

Caribbean

440 000440 000

Latin America1.5 million1.5 million

East Asia & Pacific

1.2 million1.2 million

Resource Poor Settings

Should timed inseminations be recommended for HIV discordant couples that want to have children?

• Fertility work-up

• Treatment of STIs

Under development: sperm-friendly vaginal microbicides.