A decade of the United Kingdom sperm-washing program: untangling the transatlantic divide

Accessibility and availability of assistant reproductive technology for people living with HIV in Europe: a thematic literature review

As antiretroviral therapies have transformed HIV into a manageable chronic disease, many individuals have or will choose to have children, and the use of assisted reproductive technology can serve as an effective risk-reducing strategy. In this thematic literature review, we examine the state of research on access to and availability of assisted reproductive health technologies for people living with HIV in Europe, with the aim of identifying gaps for further research. We find that the existing literature is focused on serodiscordant couples consisting of an HIV-positive man and an HIV-negative women. This is in part because more treatment options are available for men living with HIV than women, reflecting underlying gender discrimination in treatment. The existing scholarship largely ignores reproductive options for seroconcordant couples or single individuals, or for men and women with underlying infertility. Finally, very little research addresses the question of financial affordability, which is a known barrier to infertility treatment.

Perceptions of pregnancy occurring among HIV-serodiscordant couples in Kenya

BACKGROUND

Among HIV serodiscordant couples, most conception involves condomless sex and may confer a period with increased HIV transmission risk if HIV viral load is not suppressed and other precautions are not used. Safer conception strategies enable HIV serodiscordant couples to attain their pregnancy goals while markedly reducing this risk. We explored the perceptions and beliefs held by HIV serodiscordant couples and health care providers concerning pregnancy among HIV serodiscordant couples in Kenya and gathered their thoughts about how these might influence use of safer conception methods.

METHODS

We conducted 20 Key Informant Interviews (KIIs) with health care providers offering safer conception counseling and 21 In-Depth Interviews (IDIs) and 4 Focus Group Discussions (FGDs) with members of HIV serodiscordant couples with immediate pregnancy goals in Thika, Kenya. Data were analyzed using an inductive approach that identified two emergent themes: perceptions towards pregnancy among HIV serodiscordant couples and access to safer conception services.

RESULTS

The perceptions held by the community towards couples in HIV serodiscordant relationships having children were largely negative. The participants were aware of the increased HIV transmission risk to the HIV uninfected partners while trying to become pregnant. In the community, having biological children was cherished yet the majority of the couples shied away from accessing safer conception services offered at health facilities due to stigma and lack of knowledge of the existence of such services. Some providers had limited knowledge on safer conception strategies and services and consequently discouraged HIV serodiscordant couples from natural conception.

CONCLUSIONS

Negative perceptions towards HIV serodiscordant couples becoming pregnant has hindered access to safer conception services. Therefore, there is need to create a supportive environment for HIV serodiscordant couples with fertility intentions that normalizes their desire to have children and informs the community about the availability of safer conception services.

[Assisted reproductive technologies in HIV patients: Which results and which strategy in France in 2019?]

With the use of antiretroviral therapy, HIV transmission from mother to fetus and between sexual partners has been significantly reduced, successively allowing pregnancy, then assisted reproductive technologies, and targeted unprotected sex among couples living with HIV. Since first French Morlat report in 2013, natural procreation is now possible under certain conditions for these couples living with HIV and the use of assisted reproductive technologies is increasingly limited to the treatment of infertility. While the results of intrauterine insemination seem satisfactory for serodiscordant couples living with HIV, in vitro fertilization results appear to be unfavorable when the woman is infected with HIV. In vitro fertilization results appear to be comparable to those in general population when only the man is infected with HIV. It can be assumed that ovaries are impacted by the treatment and/or the HIV in infected women.

Delivering safer conception services to HIV serodiscordant couples in Kenya: perspectives from healthcare providers and HIV serodiscordant couples

Introduction: For HIV serodiscordant couples in resource-limited settings, pregnancy is common despite the risk of sexual and/or perinatal HIV transmission. Some safer conception strategies to reduce HIV transmission during pregnancy attempts are available but often not used for reasons including knowledge, accessibility, preference and others. We sought to understand Kenyan health providers’ and HIV serodiscordant couples’ perspectives and experiences with safer conception.

Methods: Between August 2015 and March 2016, we conducted key informant interviews (KIIs) with health providers from public and private HIV care and fertility clinics and in-depth interviews (IDIs) and focus group discussions (FGDs) with HIV serodiscordant couples participating in an open-label study of integrated pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for HIV prevention (the Partners Demonstration Project). An inductive analytic approach identified a number of themes related to experiences with and perceptions of safer conception strategies.

Results: We conducted 20 KIIs with health providers, and 21 IDIs and 4 FGDs with HIV serodiscordant couples. HIV clinic providers frequently discussed timed condomless sex and antiretroviral medications while providers at private fertility care centres were more comfortable recommending medically assisted reproduction. Couples experienced with ART and PrEP reported that they were comfortable using these strategies to reduce HIV risk when attempting pregnancy. Timed condomless sex in conjunction with ART and PrEP was a preferred strategy, often owing to them being available for free in public and research clinics, as well as most widely known; however, couples often held inaccurate knowledge of how to identify days with peak fertility in the upcoming menstrual cycle.

Conclusions: Antiretroviral-based HIV prevention is acceptable and accessible to meet the growing demand for safer conception services in Kenya, since medically assisted interventions are currently cost prohibitive. Cross-disciplinary training for health providers would expand confidence in all prevention options and foster the tailoring of counselling to couples’ preferences.

Reclaiming fertility awareness methods to inform timed intercourse for HIV serodiscordant couples attempting to conceive

INTRODUCTION

Increased life expectancy of HIV-positive individuals during recent years has drawn attention to their quality of life, which includes fulfillment of fertility desires. In particular, heterosexual HIV serodiscordant couples constitute a special group for whom the balance between desired pregnancy and the risk of viral transmission should be carefully considered and optimized. Although advanced assisted reproductive technologies are available, such treatments are expensive and are often unavailable. Moreover, standard viral load testing and antiretroviral therapy may not be accessible due to structural or individual barriers. To reduce the risk of HIV transmission, a lower cost alternative is timed condomless sex combined with other risk-reduction strategies. However, timed condomless sex requires specific knowledge of how to accurately predict the fertile window in a menstrual cycle. The aim of this study was to summarize inexpensive fertility awareness methods (FAMs) that predict the fertile window and may be useful for counselling HIV-positive couples on lower cost options to conceive.

METHODS

Original English-language research articles were identified by a detailed Medline and Embase search in July 2014. Relevant citations in the included articles were also retrieved.

RESULTS AND DISCUSSION

Calendar method, basal body temperature and cervicovaginal mucus secretions are the most accessible and sensitive FAMs, although poor specificity precludes their independent use in ovulation detection. In contrast, urinary luteinizing hormone testing is highly specific but less sensitive, and more expensive. To maximize the chance of conception per cycle, the likelihood of natural conception needs to be assessed with a basic fertility evaluation of both partners and a combination of FAMs should be offered. Adherence to other risk-reduction strategies should also be advised, and timely referral to reproductive medicine specialists is necessary when sub/infertility is suspected.

CONCLUSIONS

FAMs provide effective, economical and accessible options for HIV serodiscordant couples to conceive while minimizing unnecessary viral exposure. It is important for health care providers to initiate conversations about fertility desires in HIV-positive couples and to educate identified couples on safer conception strategies.

Fertility treatment options for HIV-infected individuals

Many HIV-serodiscordant couples desire children and physician-assisted techniques can help individuals achieve pregnancy while reducing the risk of seroconversion in their seronegative partner. For HIV-seropositive males, sperm washing with intrauterine insemination (SW-IUI) was introduced in Europe in the early 1990s, while in the USA in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) has been primarily used to reduce the risk of viral transmission. When properly applied to well-selected populations, no seroconversion has been reported with either of these methods. Within the last 5 years, randomized controlled studies have demonstrated the efficacy of daily pre-exposure prophylaxis in reducing the risk of seroconversion in couples having intercourse when an HIV-seropositive male has undetectable viral loads. In both the USA and Europe, favorable reproductive outcomes have been reported for HIV-seropositive females undergoing IUI and IVF-ICSI. Herein, we review the use of various contemporary reproductive techniques available to HIV-serodiscordant couples interested in having children, including new data on cumulative clinical pregnancy rates and cumulative live-birth rates after IVF-ICSI for male serodiscordant couples. We conclude by proposing that pre-exposure prophylaxis with SW-IUI may be a safe, economical and effective alternative for achieving pregnancy in well-selected, monogamous HIV-serodiscordant couples where the male partner is seropositive.

Antiretrovirals and safer conception for HIV-serodiscordant couples

PURPOSE OF REVIEW

Many men and women living with HIV and their uninfected partners attempt to conceive children. HIV-prevention science can be applied to reduce sexual transmission risk while respecting couples' reproductive goals. Here we discuss antiretrovirals as prevention in the context of safer conception for HIV-serodiscordant couples.

RECENT FINDINGS

Antiretroviral therapy (ART) for the infected partner and pre-exposure prophylaxis (PrEP) for the uninfected partner reduce the risk of heterosexual HIV transmission. Several demonstration projects suggest the feasibility and acceptability of antiretroviral (ARV)s as periconception HIV-prevention for HIV-serodiscordant couples. The application of ARVs to periconception risk reduction may be limited by adherence.

SUMMARY

For male-infected (M+F-) couples who cannot access sperm processing and female-infected (F+M-) couples unwilling to carry out insemination without intercourse, ART for the infected partner, PrEP for the uninfected partner, combined with treatment for sexually transmitted infections, sex limited to peak fertility, and medical male circumcision (for F+M couples) provide excellent, well tolerated options for reducing the risk of periconception HIV sexual transmission.

Women with pregnancies had lower adherence to 1% tenofovir vaginal gel as HIV preexposure prophylaxis in CAPRISA 004, a phase IIB randomized-controlled trial

Background

Antiretroviral prophylaxis may be a critical strategy to reduce periconception HIV transmission. Maximizing the benefit of periconception pharmacologic HIV risk-reduction requires an understanding of the links between pregnancy and adherence to this prevention strategy.

Methods

We assessed study gel adherence among women with pregnancies compared to women without pregnancies enrolled in the CAPRISA 004 phase IIB trial of 1% vaginal tenofovir gel. Pregnancy was assessed with monthly urine tests. Adherence was measured monthly and defined as proportion of sex acts covered by two returned, used applicators based on pre- and post-coital dosing. High adherence was defined as a median adherence score of >80%, that is, more than 80% of sex acts were covered by two applications of study gel. A multivariate generalized estimating equations (GEE) model with a binomial distribution was used to assess covariates associated with high adherence (>80%) over time. Median adherence before and after pregnancy was compared using Wilcoxon signed rank test.

Results

Among 868 women, 53 had at least 1 pregnancy (4.06 per 100 woman years, 95% CI: 3.04, 5.31). Women with pregnancies had lower median adherence compared to women without pregnancies (50% [IQR: 45–83] vs. 60% [IQR: 50–100], p = 0.02). Women with pregnancies also had a 48% lower odds of high adherence compared to women without pregnancies when adjusting for confounders (aOR 0.52, 95%CI: 0.41–0.66, p<0.0001). Among women with pregnancies, adherence before and after pregnancy was not different (50% [IQR: 46–83] vs. 55% [IQR: 20–100], p = 0.68).

Conclusions

Women with pregnancies were less likely to have high adherence to study gel compared to women without pregnancies. Understanding these differences may inform findings from HIV prevention trials and future implementation of antiretroviral prophylaxis for at-risk women who choose to conceive. The protocol for the parent trial is registered on ClinicalTrials.gov, NCT00441298, http://www.clinicaltrials.gov/ct2/show/NCT00441298.

Reproductive decision-making and periconception practices among HIV-positive men and women attending HIV services in Durban, South Africa

Understanding reproductive decisions and periconception behavior among HIV-discordant couples is important for designing risk reduction interventions for couples who choose to conceive. In-depth interviews were conducted to explore reproductive decision-making and periconception practices among HIV-positive women with recent pregnancy (n = 30), and HIV-positive men (n = 20), all reporting partners of negative or unknown HIV-status, and attending HIV services in Durban, South Africa. Transcripts were coded for categories and emergent themes. Participants expressed strong reasons for having children, but rarely knew how to reduce periconception HIV transmission. Pregnancy planning occurred on a spectrum ranging from explicitly intended to explicitly unintended, with many falling in between the two extremes. Male fertility desire and misunderstanding serodiscordance contributed to HIV risk behavior. Participants expressed openness to healthcare worker advice for safer conception and modified risk behavior post-conception, suggesting the feasibility of safer conception interventions which may target both men and women and include serodiscordance counseling and promotion of contraception.

Reproductive assistance in HIV serodiscordant couples

BACKGROUND

Three quarters of individuals infected with human immunodeficiency virus (HIV) are in their reproductive years and may consider pregnancy planning. Techniques have been developed which can minimize the risk of HIV transmission in these couples, and the current literature on this topic is reviewed here.

METHODS

We reviewed the literature for the following topics: risk of HIV transmission, effects of HIV infection on fertility, reproductive assistance in industrialized and low-income countries, pre-exposure chemoprophylaxis (PrEP) and timed intercourse in HIV-discordant couples for both male and female positivity. Relevant publications were identified through searches of the EMBASE Medline and PubMed databases, the Google-indexed scientific literature and periodic specialized magazines from the on-line Library Service of the University of Milan, Italy.

RESULTS

In serodiscordant couples in which the man is positive, the primary method used to prevent HIV transmission is 'sperm washing', followed by IUI or IVF. Data show that sperm washing in HIV-positive men has not produced seroconversion in women or their offspring; however, the evidence is limited. Recently, increasing evidence describing PrEP for HIV prevention has been published and PrEP could be an alternative to ART for fertile couples. Usually HIV-infected women undergo self-insemination around the time of ovulation. Few studies have been published on IVF outcome in HIV-infected women.

CONCLUSIONS

Assisted reproduction programmes should be integrated into global public health services against HIV. For HIV serodiscordant couples with infected men, sperm washing should be the first choice. However, timed intercourse and PrEP for HIV prevention has been reported. Recent data highlight the possible impairment of fertility in HIV-infected women. Efforts to design a multicentric study should be strengthened.

Endemic Venezuelan equine encephalitis in the Americas: hidden under the dengue umbrella

Venezuelan equine encephalitis (VEE) is an emerging infectious disease in Latin America. Outbreaks have been recorded for decades in countries with enzootic circulation, and the recent implementation of surveillance systems has allowed the detection of additional human cases in countries and areas with previously unknown VEE activity. Clinically, VEE is indistinguishable from dengue and other arboviral diseases and confirmatory diagnosis requires the use of specialized laboratory tests that are difficult to afford in resource-limited regions. Thus, the disease burden of endemic VEE in developing countries remains largely unknown, but recent surveillance suggests that it may represent up to 10% of the dengue burden in neotropical cities, or tens-of-thousands of cases per year throughout Latin America. The potential emergence of epizootic viruses from enzootic progenitors further highlights the need to strengthen surveillance activities, identify mosquito vectors and reservoirs and develop effective strategies to control the disease. In this article, we provide an overview of the current status of endemic VEE that results from spillover of the enzootic cycles, and we discuss public health measures for disease control as well as future avenues for VEE research.

Sperm washing to prevent HIV transmission from HIV-infected men but allowing conception in sero-discordant couples

BACKGROUND

Sperm washing is a term used to describe the process in which individual spermatozoa are separated from the seminal fluid. Sperm washing is used to prevent HIV transmission but allow conception in sero-discordant couples, where the male is HIV positive, but the female is HIV negative. This procedure is based on the observation that HIV cannot attach itself to spermatozoa, but it can be found in the fluid and cells surrounding spermatozoa.

OBJECTIVES

To determine the benefits and harms of sperm washing of HIV-infected males when used to prevent the transmission of HIV but allowing conception in the HIV-negative female.

SEARCH STRATEGY

We searched the Cochrane HIV/AIDS Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCORPUS, AIDsearch, AJOL, LILACS and INDEX MEDICUS. We also searched the following conference proceedings for relevant abstracts:The International AIDS Conference; The Conference on Retroviruses and Opportunistic Infections (CROI); The British HIV Association (BHIVA) Conference; The International Conference of Obstetricians and Gynecologists (FIGO); The American Academy of HIV Medicine Conference; The Australasian HIV/AIDS Conference; The American Society for Reproductive Medicine (ASRM) conferences and website; The European Society for Human Reproduction and Embryology (ESHRE) conferences and websites, and the British Fertility Society (BFS) conferences and website. We also conducted a search of the website: www.ClinicalTrials.gov. The date of the most recent Cochrane HIV/AIDS Group Controlled Trials Register search was on the 10th of November, 2010.

SELECTION CRITERIA

We preferentially looked for randomised or quasi-randomised controlled trials on sperm washing, aimed at preventing HIV transmission from HIV infected men but allowing conception in sero-discordant couples, irrespective of publication status, year of publication, or language in the review.

DATA COLLECTION AND ANALYSIS

No relevant trials were identified for inclusion in this review.

MAIN RESULTS

Forty four studies were identified, but none of them were suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

Reports on the use of sperm washing to prevent HIV transmission from HIV infected men but allowing conception in sero-discordant couples is currently limited to observational studies. No randomised controlled trial has assessed the benefit or risk of sperm washing to prevent HIV transmission from HIV infected men but allow conception in sero-discordant couples. Thus, this systematic review identifies the need for a multicentre randomised controlled trial assessing the benefits and possible risks of sperm washing in preventing HIV transmission from HIV infected men but allow conception in sero-discordant couples.