Case Series of Fertility Treatment in HIV-Discordant Couples (Male Positive, Female Negative): The Ontario Experience

Abstract

The success of combination antiretroviral therapies for the treatment of human immunodeficiency virus (HIV) has resulted in prolonged life expectancy (over 40 years from diagnosis) and an improved quality of life for people living with HIV. The risk of vertical HIV transmission during pregnancy has been reduced to less than 1%. As a result of these breakthroughs and as many of these individuals are of reproductive age, fertility issues are becoming increasingly important for this population. One population in which conception planning and reduction of horizontal HIV transmission warrants further research is HIV-discordant couples where the male partner is HIV-positive and the female partner is HIV-negative. Sperm washing is a technique carried out in a fertility clinic that separates HIV from the seminal fluid. Although sperm washing followed by intrauterine insemination significantly reduces the risk of horizontal HIV transmission, there has been limited access to the procedure in North America. Furthermore, little is known about the conception decision-making experiences of HIV-discordant couples who might benefit from sperm washing. Chart reviews and semi-structured interviews were completed with 12 HIV-discordant couples in Ontario, Canada. Couples were recruited through HIV clinics and one fertility clinic that offered sperm washing. Participants identified a number of factors that affected their decision-making around pregnancy planning. Access to sperm washing and other fertility services was an issue (cost, travel and few clinics). Participants identified a lack of information on the procedure (availability, safety). Sources of support (social networks, healthcare providers) were unevenly distributed, especially among those who did not disclose their HIV status to friends and family. Finally, the stigmatisation of HIV continues to have a negative affect on HIV-discordant couples and their intentions to conceive. Access to sperm washing and fertility service is significantly limited for this population and is accompanied with a number of challenges.

A Social Ecological Approach to Exploring Barriers to Accessing Sexual and Reproductive Health Services among Couples Living with HIV in Southern Malawi

“…Health workers continue stigmatizing CLWH who access sexual and reproductive health services. Similar findings have also been noted by Agadjanian and Hayford, [13], Cooper et al, [35], BeyezaKashesya et al, [36], Newmeyer et al, [15], and Nóbrega et al, [37]. We are aware that if the finding is ignored, it raises biomedical concerns about the risk of HIV super infection, viral recombination, and transmission of drug-resistant virus in cases where unprotected sex is practiced.…”

“…Studies from Africa suggest that HIV might modify, but not eliminate, broader desires to have children [2,13,14] and ART use may be associated with increased fertility desire among PLWH possibly through increased hopes for the future. These decisions are related to the "Lazarus effect" [15] where PLWH perceive that ARV allows them to live longer, and, have more "normal" social sexual lives, and possibly have healthy, HIV-negative children [4,9]. Consequently, worldwide there has been a shift in research, whereby efforts are now integrating reproductive health in the care and management of PLWH [8,14].…”

Canadian HIV Pregnancy Planning Guidelines

“…Some important procedures were also less commonly available to people living with HIV. In particular, sperm washing was available in only 26% of clinics in 4 provinces, a service gap noted in the Newmeyer et al study that described the barriers to services experienced by people living with HIV [14].…”

“…Clinicians should review all medications that HIV-positive men and women may be using, including antidepressants, pain medications, over-the-counter medications, and hepatitis treatment, to ensure that they are safe during conception and pregnancy. (II-3A) 14. All HIV-positive men and women who require combination antiretroviral therapy for their own health during the pre-conception period should be advised to continue their current regimens, but women should not take any drugs that are potentially teratogenic or considered toxic in pregnancy, substituting other drugs when necessary or possible.…”

In search of a face: Childbearing decisions among couples living with HIV from rural southern Malawi

“…Despite the demonstrated interest in having children amongst PLWH, the medical community has continued to be slow to give support and has even discouraged PLWH from pursuing their right to pregnancy (Gruskin et al 2007, Agadjanian and Hayford 2009, Cooper et al 2009, Kashesya Beyeza et al 2009, Kelly et al 2011, Newmeyer et al 2011. This resistance has persisted despite significant medical advances that have both increased life expectancy after HIV diagnosis and reduced vertical transmission to less than 2% (Kanniappan et al 2008, Chasela et al 2010.…”