People living with HIV and procreation: 30 years of progress from prohibition to freedom?

HIV-, HBV-, and HCV-Related Information on U.S. Fertility Clinic Websites: A Content Analysis

Purpose: People living with human immunodeficiency virus, hepatitis B virus, or hepatitis C virus (PLHIV/HBV/HCV) face barriers to assisted reproductive technologies (ART), in part, due to laws and professional regulations mandating dedicated laboratory facilities and storage tanks for reproductive tissue to minimize theoretical risk of cross-contamination. These guidelines greatly increase the expense of providing equal care, however, fertility clinics are neither required to treat nor disclose whether they treat PLHIV/HBV/HCV. Clinics' websites are an important source of information regarding available services for prospective patients and referring providers. We assessed whether clinic websites disclose availability of ART for PLHIV/HBV/HCV.

Methods: Websites for Society for Assisted Reproductive Technology-accredited clinics in Northeast and South Atlantic United States were searched systematically for HIV-, HBV-, or HCV-specific content. Qualitative and thematic analysis was performed. Clinic characteristics (annual volume, practice setting) were collected.

Results: Of 136 websites, nine (6.6%) had information relevant to PLHIV seeking infertility treatment, and seven (5.1%) offered at least some treatments. Three clinics (2.2%) also mentioned treatment information relevant for PLHBV/HCV, one of which offered treatment. Information was often difficult to find or interpret. By contrast, 77/136 (56.6%) of clinics mentioned universally screening patients for HIV and 77/136 (56.6%) mentioned screening for HBV/HCV before ART.

Conclusion: Given economic disincentives to providing ART to PLHIV/HBV/HCV under current guidelines, the paucity of clinics openly offering treatment suggests a troubling lack of transparency or, possibly, a lack of available care. Further research should examine the impact of current guidelines and whether dedicated facilities and storage are medically indicated.

Awareness and Understanding of HIV Non-disclosure Case Law and the Role of Healthcare Providers in Discussions About the Criminalization of HIV Non-disclosure Among Women Living with HIV in Canada

In 2012, the Supreme Court of Canada ruled that people with HIV are legally obligated to disclose their serostatus before sex with a "realistic possibility" of HIV transmission, suggesting a legal obligation to disclose unless they use condoms and have a low HIV viral load (< 1500 copies/mL). We measured prevalence and correlates of ruling awareness among 1230 women with HIV enrolled in a community-based cohort study (2015-2017). While 899 (73%) participants had ruling awareness, only 37% were both aware of and understood ruling components. Among 899 aware participants, 34% had never discussed disclosure and the law with healthcare providers, despite only 5% being unwilling to do this. Detectable/unknown HIV viral load, lack of awareness of prevention benefits of antiretroviral therapy, education ≤ high-school and high HIV-related stigma were negatively associated with ruling awareness. Discussions around disclosure and the law in community and healthcare settings are warranted to support women with HIV.

Natural Conception is Safe for HIV-Serodiscordant Couples with Persistent Suppressive Antiretroviral Therapy for the Infected Partner

Background: Sustained use of antiretroviral treatment to achieve a suppressed viral load in persons living with HIV is associated with zero or near-zero risk of sexual and vertical HIV transmission. This has led to an increasing number of HIV-serodiscordant couples (SDCs) who wish to have children. The aim of this study was to describe the most recent results of a protocol for reproductive counseling directed at HIV-SDCs who desire natural conception and to identify some of the factors influencing reproductive success. Methods: Two hundred fourteen couples were enrolled. Sociodemographic/behavioral and clinical data were collected. CD4+ lymphocyte count, HIV viral load, serology/viral load of hepatitis B/C viruses, syphilis serology, and other sexually transmitted infection diagnosis in both members of couple; spermiogram in men, HIV proviral and viral load in semen of male HIV-infected partners, and urine luteinizing hormone qualitative test in women were performed. Unprotected vaginal intercourses, pregnancies achieved, and their outcomes were recorded. Results: After almost 10,000 sexual relations, a total of 188 pregnancies was achieved, 62% of couples became pregnant once or several times with no HIV transmission to either the partner or the offspring. Younger age of woman, no fertility disorders in both members of couple, and no treatment with efavirenz in men were factors related with reproductive success. Conclusions: Natural conception, under controlled conditions, can be offered to SDCs who wish to have children as a safe method of conception and its effectiveness seems to be related to factors not different from those of the general population.

Reduced fecundity in HIV-positive women

STUDY QUESTION

Is HIV associated with increased time to pregnancy (TTP)?

SUMMARY ANSWER

HIV-positive women who discontinue a contraceptive method to become pregnant have increased TTP, particularly among those who likely do not know their status.

WHAT IS KNOWN ALREADY

HIV-positive women have fewer children on average than their HIV-negative counterparts due to both behavioral and biological factors. There is a need to better describe and quantify fecundity patterns associated with HIV in the general population.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study was based on data from 12 Demographic and Health Surveys (DHSs) conducted between 2003 and 2013 in 11 African countries. All studies collected dried blood spot samples for HIV testing and included a retrospective calendar module that recorded women's monthly reproductive status in the 5 years preceding the survey. TTP was measured among 3181 women discontinuing a contraceptive method within 2 years of the survey in order to become pregnant.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We use Cox proportional hazard models for discrete survival data to model TTP and estimate fecundability odds ratios (FOR) and 95% CIs for the 12-month period following contraceptive discontinuation. In addition to employing a binary measure of HIV status, we also develop an additional explanatory measure that combines HIV status with information on whether respondents had ever been tested for HIV and received their results (which proxies for knowledge of HIV status) to reduce the threat of confounding from behavioral changes following an HIV diagnosis.

MAIN RESULTS AND THE ROLE OF CHANCE

In our sample, 10.3% of women were HIV-positive, and a little more than half (51.8%) of women received test results and likely knew their status. Over a 12-month observation period, HIV-positive women had a 25% average reduction in fecundity compared to HIV-negative women [adjusted FOR (aFOR) = 0.75 (0.62-0.92)] after adjusting for confounders. The 12-month fecundity patterns differed by women's likely knowledge of their status such that results were primarily driven by HIV-positive women who likely did not know their status. Moreover, reductions in fecundity attributable to HIV were not uniform over time. Among women who were still trying for pregnancy after 3 unsuccessful months, HIV-positive women had half the odds of becoming pregnant compared to HIV-negative women [aFOR = 0.50 (0.35-0.71)]. Conversely, there were no significant differences in FORs between HIV-negative and HIV-positive women in the first 3 months.

LIMITATIONS REASONS FOR CAUTION

Because dried blood spot samples for HIV testing were collected at the time of the survey but reproductive calendar data were collected retrospectively, it is possible that we introduced misclassification bias, as we have no knowledge if the acquisition of HIV occurred before or after pregnancy attempt.

WIDER IMPLICATIONS OF THE FINDINGS

As life expectancy and quality health status improve due to earlier initiation of antiretroviral (ARV) treatment in HIV-positive women, there has been growing awareness that services should also address the fertility desires of HIV-positive women who want children. These findings indicate that if a pregnancy does not occur after 3 months of attempting pregnancy, HIV-positive women and HIV-discordant couples should request access to HIV and reproductive pre-pregnancy counseling and health assessments.

STUDY FUNDING/COMPETING INTEREST(S)

A.G. was supported by the National Institutes of Health (contract T32-HD007275) during the study. During the conceptualization, data collection and analysis time frame, S.vdP. was supported by WHO/RHR/HRP Special Program in Reproductive Health and Research, Geneva, Switzerland, and HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). The authors have no conflicts of interest to declare.

Transmission of hepatitis D virus between spouses: A longitudinal study of the first reported Canadian case

In chronic hepatitis B (CHB), hepatitis D virus (HDV) superinfection can lead to acute liver failure. The incidence of HDV superinfection is unknown, but is often detected in immigrants from HDV endemic countries. In this report, we characterize long-term clinical and virological outcomes in a hepatitis B virus (HBV) infected carrier before and after HDV superinfection, acquired from their spouse having HBV/HDV co-infection. A 38 year-old Mongolian male with CHB on anti-HBV therapy developed acute liver failure following HDV superinfection. Although he recovered, avoiding the need for liver transplant, HDV serological and molecular markers of infection persisted for the subsequent 16-month follow-up period, suggesting the development of CHB/HDV co-infection. The source of his HDV was from his wife of 10 years, a 34-year old Mongolian female known to have inactive CHB/HDV co-infection but who was not on anti-HBV therapy. Phylogenetic analysis of the complete HDV genome from the couple showed >99% similarity, with post-transmission longitudinal sequence revealing specific nucleotide substitutions between both spouse’s HDV genome sequences. This study highlights the ongoing risk of HDV superinfection due to long-term co-habitation or sexual transmission in CHB patients. The fact that transmission occurred after almost a decade of marriage may be due to host immune or environmental factors that created a more favorable condition for transmission.

Fertility care interventions should be provided as the first line options for HIV+ serodiscordant couples who desire children in settings with affordable access to care, regardless of their fertility status

INTRODUCTION

With increasing life expectancy, couples with at least one partner afflicted with HIV are more commonly pursuing the opportunity to have biologic offspring. Currently, there are no universally accepted recommendations regarding first line reproductive treatments for HIV serodiscordant couples lacking a history of infertility. We strongly believe that fertility care intervention should be the first line treatment, when affordably accessible, over natural conception for HIV serodiscordant couples to achieve pregnancy in a safe and efficacious manner.

Discussion

In the era of highly active anti-retroviral therapy, in combination with timed intercourse and pre-exposure prophylaxis for the HIV negative partner, some members of the medical community are arguing in favour of natural conception as a means of achieving pregnancy in this patient population. In our opinion, laboratory assisted fertility methods, including intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection with semen washing should be the first line treatment recommendation for HIV serodiscordant couples desiring pregnancy for the following reasons: (1) abundance of evidence in the medical literature supporting the safety profile and efficacy of fertility care intervention in couples with HIV; paucity of data addressing safety of natural conception in comparison to fertility intervention techniques (2) unknown public health impact of promoting natural conception as a safe means of achieving pregnancy (3) ethical implications: patients should be offered the available and accessible treatment option posing the lowest possible known risk to the uninfected partner.

Conclusions

We believe that physician assisted fertility care, when affordably accessible, should be the treatment of choice over natural conception. While the preliminary data on natural conception in couples using highly active anti-retroviral therapy/pre-exposure prophylaxis/timed intercourse appears promising, we believe that this approach should be limited to patients in resource poor settings where more sophisticated measures do not exist or for patients that simply cannot afford subspecialty care. There are likely to be unknown psychological and behavioural factors impacted by promoting natural conception and diminishing the importance of safe sex practices. Additionally, it is our moral obligation to patients to offer the affordably accessible treatment interventions that pose the least known risk when considering reproductive options.