I SIMPOSIO INTERNACIONAL I SIMPOSIO INTERNACIONAL de REPRODUCCION y HIVde REPRODUCCION y HIV

CONCEPTS AND DATA FOR THE PRESSCONCEPTS AND DATA FOR THE PRESS

Dr Augusto E SempriniDr Augusto E SempriniUniversity of Milan & University College of LondonUniversity of Milan & University College of London

Dr Sergio PasqualiniDr Sergio PasqualiniHalitus Instituto MedicoHalitus Instituto Medico

The Problem: HIV in Semen

SEXUAL TRANSMISSION OF HIVSEXUAL TRANSMISSION OF HIV

+ -InfectivityInfectivity

Sexual contactSexual contact

SusceptibilitySusceptibility

DISCLOSURE OF HIV DISCLOSURE OF HIV INFECTION DIAGNOSISINFECTION DIAGNOSIS

FEARS OF:

•DISABILITY AND DEATH

•SOCIAL OUTCASTING

•PROBLEMS WITH PROFESSIONAL LIFE

•LIMITATIONS IN PERSONAL LIFE

•BEING UNABLE TO HAVE A HEALTHY CHILD

COUPLES WITH HIVCOUPLES WITH HIV•Man with HIV & uninfected woman

•Woman with HIV & uninfected man

•Both partners with HIV (same viral strain)

•Both partners with HIV (different viral strains)

REPRODUCTION AND HIVREPRODUCTION AND HIV

REPRODUCTIVE COUNSELLING

&

REPRODUCTIVE ASSISTANCE

EUROPE 2001EUROPE 2001•IN THE EU THERE ARE PROBABLY 250.000 TO 500.000

INDIVIDUALS AGED BETWEEN 19 AND 34 YEARS WHO

ARE INFECTED WITH HIV

•THERE MAY BE 200.000 TO 400.000 UNINFECTED

PARTNERS AT RISK OF SEXUAL ACQUISITION OF HIV

•ACCORDING TO THE RATE OF SEXUAL AND

VERTICAL TRANSMISSION, THERE MAY BE 30.000 TO

4.000 UNBORN INFANTS AT RISK OF ACQUISITION OF

HIV FROM THE INFECTED MOTHER

COUPLES WITH HIVCOUPLES WITH HIV•In Europe most cases of infection with HIV derive

from the use of intravenous drugs

•Drug use is a prevalently male behaviour (male to

female ratio 4/1)

•Most male drug users are heterosexual (> 95%)

•Young uninfected females are at risk of acquiring HIV

from these HIV-infected males

COUPLES WITH HIVCOUPLES WITH HIV

•Women at highest risk of sexual acquisition of HIV

are the habitual partners of HIV-infected males

•In Italy three out of four new cases of heterosexual

transmission of HIV are females

•Less than 50% of HIV-discordant couples regularly

recur to condom protected intercourse

•HIV-discordant couples should be motivated to

avoid any risk of infection for the healthy partner

ARE THE REPRODUCTIVE RIGHTS OF ARE THE REPRODUCTIVE RIGHTS OF PEOPLE INFECTED WITH HIV PEOPLE INFECTED WITH HIV

RESPECTED ?RESPECTED ?

THERE IS A NUMBER OF TRANSMISSIBILE

CONDITIONS THAT ARE NOT REGARDED AS A

REASON TO DISCOURAGE PROSPECTIVE PARENTS

OF POTENTIALLY AFFECTED CHILDREN FROM

TRYING FOR A PREGNANCY, IS IT THE SAME FOR

HIV ?

GOALS OF REPRODUCTIVE COUNSELLING TO HIV DISCORDANT COUPLES

•OFFER NON-JUDGMENTAL UNBIASED INFORMATION TO LIMIT THE RISK OF TRANSMITTING THE INFECTION TO THE UNINFECTED PARTNER AND TO THE INFANT•HELP TO REDUCE THE RISK OF TOXIC CONSEQUNECES OF ANTIRETROVIRAL THERAPY TO THE OFFSPRING

SECONDARY GOALS OF REPRODUCTIVE SECONDARY GOALS OF REPRODUCTIVE COUNSELLING TO HIV DISCORDANT COUNSELLING TO HIV DISCORDANT

COUPLESCOUPLES

•HELP THE INDIVIDUAL WITH HIV TO

ELABORATE ITS DESIRE OF PARENTHOOD

•REINFORCE THE BENEFITS OF AVODING

SEXUAL TRANSMISSION OF HIV TO THE

UNINFECTED PARTNER BEFORE AND

AFTER PREGNANCY

WHAT ABOUT WHAT ABOUT

REPRODUCTIVE REPRODUCTIVE

ASSISTANCE ?ASSISTANCE ?

REMOVAL OF p18 IMMUNOREACTIVE CELLS REMOVAL OF p18 IMMUNOREACTIVE CELLS FROM THE SEMEN OF HTLV-III/LAV FROM THE SEMEN OF HTLV-III/LAV SEROPOSITIVE MENSEROPOSITIVE MENAugusto E Semprini, A Vucetich, E Morandi, CL Parravicini, G Augusto E Semprini, A Vucetich, E Morandi, CL Parravicini, G Pardi and AE Beer. Colloque INSERM, Vol. 154, 1987, pp 462Pardi and AE Beer. Colloque INSERM, Vol. 154, 1987, pp 462

A cytospin preparation of washed spermatozoa, supernatant and the A cytospin preparation of washed spermatozoa, supernatant and the second fraction of the ejaculate were chloroform-acetone fixed and second fraction of the ejaculate were chloroform-acetone fixed and tested against a monoclonal anti-p18 antibody by immunoperoxidase tested against a monoclonal anti-p18 antibody by immunoperoxidase technique. Washed sperm of seropositive and seronegative men was technique. Washed sperm of seropositive and seronegative men was non-reactive, while many mononuclear cells and those in the second non-reactive, while many mononuclear cells and those in the second fraction of seropostive males were strongly reactive. fraction of seropostive males were strongly reactive. Experiments are Experiments are under way to test the possibility of safe intrauterine insemination under way to test the possibility of safe intrauterine insemination with processed semen of HIV-positive men desiring a child.with processed semen of HIV-positive men desiring a child.

l

45%

90%

Gradiente MigrationLavado

Wash,1/8 PCR

LAVADO DEL SEMENSemprini et al. The Lancet, 27 November 1992

Dilucion al final del procedimiento: 4 x 106

INSEMINATION OF HIV-NEGATIVE WOMEN WITH INSEMINATION OF HIV-NEGATIVE WOMEN WITH PROCESSED SEMEN OF HIV-POSITIVE PARTNERSPROCESSED SEMEN OF HIV-POSITIVE PARTNERS

85 HIV-discordant couples were screened for fertility; 29 women were found suitable for a timed insemination course with the processed semen of their HIV-positive partner. None of the inseminated women seroconverted and 17 pregnancies were achieved in 15 women. All 10 infants born to these mothers remain HIV seronegative.

(Semprini et al. - Lancet 1992; 340: 1317-19)

Insemination of HIV-negative women with Insemination of HIV-negative women with processed semen of HIV-positive partnersprocessed semen of HIV-positive partners (Brian R Edlin and Scott D Holmberg Lancet, February 27 1993)

Dr Semprini et al. (Lancet, November 1992) conclude that

the lack of HIV transmission during their artificial

insemination attempt in HIV-discordant couples is

“reassuring” and suggest that this outcome is used in

counselling such couples to “give them hope of having

healthy babies”. We are concerned that their conclusions

may be overstated and could mean that physicians may

provide false hope to such couples.

ETHICAL ASPECTS OF THE INSEMINATION OF HIV-NEGATIVE WOMEN WITH PROCESSED SEMEN OF

HIV-POSITIVE PARTNERSC. La Vecchia, Human Reproduction, Vol. III, n. 3, 1993

“Nowadays the ethical aspects of medicine are complex. It is surprising how this may lead to less stringent criteria for judgement of ethical aspects by the doctors themselves, who in some case may even disregard the basic principle that in no case the life of a healthy individual should be threatened by a medical intervention. An example of this uncertainty and confusion is a recent report of the utilisation of intrauterine insemination with processed semen of HIV-positive partners for HIV-negative women.”

SPECIAL CONSIDERATIONS REARDING HIV AND SPECIAL CONSIDERATIONS REARDING HIV AND ASSISTED REPRODUCTIVE TECHNOLOGIESASSISTED REPRODUCTIVE TECHNOLOGIES

AmericanAmerican Society for Reproductive MedicineSociety for Reproductive Medicine

Fertility and Sterility Vol. 62, No. 5, November 1994Fertility and Sterility Vol. 62, No. 5, November 1994

USE OF SEMEN FROM HIV-POSITIVE PARTNERS FOR USE OF SEMEN FROM HIV-POSITIVE PARTNERS FOR INSEMINATION OF SERONEGATIVE WOMEN PARTNERSINSEMINATION OF SERONEGATIVE WOMEN PARTNERS

“The Committee recommends that the “The Committee recommends that the physician counsel physician counsel the couple regarding the risks to the woman and the couple regarding the risks to the woman and

offspring through homologous insemination by any offspring through homologous insemination by any meansmeans and that the couple consider the options of donor and that the couple consider the options of donor

insemination, adoption, or child-free living.”insemination, adoption, or child-free living.”

SPECIAL CONSIDERATIONS REARDING HIV AND SPECIAL CONSIDERATIONS REARDING HIV AND ASSISTED REPRODUCTIVE TECHNOLOGIESASSISTED REPRODUCTIVE TECHNOLOGIES

AmericanAmerican Society for Reproductive MedicineSociety for Reproductive MedicineFertility and Sterility Vol. 62, No.5, November 1994Fertility and Sterility Vol. 62, No.5, November 1994

HIV TESTING FOR COUPLES CONTEMPLATING ARTHIV TESTING FOR COUPLES CONTEMPLATING ART

“While proceeding with ART after a positive HIV test “While proceeding with ART after a positive HIV test

is not necessarily unethical, is not necessarily unethical, the Commitee the Commitee

considers HIVconsiders HIV infection a serious contraindication to infection a serious contraindication to

treatmenttreatment””

Natural conception in HIV-negative women with Natural conception in HIV-negative women with HIV- infected partnersHIV- infected partnersL Mandelbrot, I Heard, E Henrion-Geant, R Henrion (Lancet 1997; 349: 850)

We followed 104 consecutive pregnancies in 92 HIV-negative women with HIV-positive partners. Couples were advised to pinpoint ovulation in order to reduce possible exposure. Seroconversion was observed in two women at 7 months of pregnancy and in two others post partum. Some authors advocate intrauterine insemination with semen from the HIV-infected males, but the risk of this must be measured against the low background risk of natural conception. Stringent standard of safety must be required before inseminating potentially infected semen.

PROBLEMS IN REPRODUCTIVE PROBLEMS IN REPRODUCTIVE ASSISTANCE TO COUPLES WITH HIVASSISTANCE TO COUPLES WITH HIV

•WHICH PROCESSING METHOD ?WHICH PROCESSING METHOD ?

•WHICH HIV TESTING FOR SPERMATOZOA?WHICH HIV TESTING FOR SPERMATOZOA?

•WHICH CENTERS FOR ASSISTANCE?WHICH CENTERS FOR ASSISTANCE?

•WHO PAYS ?WHO PAYS ?

•HOW TO TREAT FERTILE COUPLES ?HOW TO TREAT FERTILE COUPLES ?

•HOW TO TREAT INFERTILE COUPLES ?HOW TO TREAT INFERTILE COUPLES ?

•WHICH SEROLOGICAL FOLLOW-UP ?WHICH SEROLOGICAL FOLLOW-UP ?

A NETWORK OF CENTERS PROVIDING REPRODUCTIVE ASSISTANCE TO

COUPLES WITH HIV

•COMMUNICATION BETWEEN CENTERS

•EXCHANGE OF INFORMATION

•OPTIMIZATION OF RESOURCES

•MONITORING OF THE REPRODUCTIVE

DESIRE AND NEEDS OF INDIVIDUALS AND

COUPLES WITH HIV