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we want children! how safe is sperm washing? (HIV AND PREGNANCY, 2011)
Jul 7, 2011

My name is andy, i am hiv 1 positive with cd4 count of about 700 because my cd4 is high i have not started taking my drugs,my wife is negative,we want to start having children,my question is how safe is sperm wash because i don't want to infect my wife and the child and where is the best hospital,i live in Nigeria or kindly recommend any other medical solution.

Response from Dr. Frascino

Hi, Andy.

Working closely with an HIV specialist and an HIV-knowledgable obstetrician, serodiscordant couples can reduce the risk of HIV transmission almost to zero. I'll post some recent information below plus see the link for additional information from the archives.

Good luck.

Dr. Bob

I just found out my boyfriend is HIV positive , what do I do? (PREGNANCY: HIV POSITIVE MALE AND HIV NEGATIVE FEMALE 2010) Dec 12, 2010

Hiv &Pregnancy saving lives, both baby and mom By DeBoraH CoHan, md, mPh, aahivS

IAM MEDICAL DIRECTOR of the Bay Area Perinatal AIDS Center (BAPAC) in San Francisco, CA. As part of a multidisciplinary team, I provide prenatal and preconception care for HIV-infected women, as well as HIV-uninfected women in serodiscordant relationships. I also provide gynecologic care for HIV-positive women.

I do most of my work at San Francisco General Hospital, where we see primarily uninsured patients. I am proud to work there, the site of the first HIV clinic in the world. I also am assistant director of the UCSF fellowship in reproductive infectious diseases, one of three such fellowships in the country. In addition, I am associate director of the National Perinatal HIV Hotline and Clinicians Network at UCSF/ San Francisco General Hospital.

Much of my work at BAPAC involves preconception counseling for HIV serodiscordant couples and I am increasingly providing pre- natal care for HIV negative women who have HIV positive partners. Today I saw a woman in that situation, 20 weeks pregnant, who is just now initiating prenatal care. She is HIV negative, but never uses condoms with her HIV positive partner. He is in care, but not on ARVs, contending he doesn't need them because he has a high CD4 count. Both are methamphetamine users, as well. This is the woman's fourth pregnancy, but the first planned. It is also the first time she has had prenatal care. Her previous three chil- dren have been taken away by Child Protective Services, presumably because of drug use. She is in a very chaotic social situation.

Today, we did an ultrasound and tried to get them excited, hoping to use her pregnancy as a teachable moment. We got in touch with his HIV care provider to discuss initiating ARVs for him. We engage such patients about the importance of decreasing sexual transmission, in- forming them that pregnancy may increase the risk of acquiring HIV. We want to see the positive partner on medication because that is associated with over 90 percent decrease in sexual transmission. Also, every single time we see them, we encourage condom use. We expect to see this woman weekly. Still, they were clear: they do not intend to use condoms.

I had two prior HIV negative patients this year who took preexpo- sure prophylaxis (PrEP), Truvada, during pregnancy. iPrEX showed us that PrEP can work for men who have sex with men (MSM), but the FEM-PrEP study reported in April raises questions regarding its efficacy in women.

I explained this to the patient today, but she still wants to take Tru- vada. She says she doesn't want her baby to get HIV, but she says she realistically will not start using condoms.

To this couple's credit, they came to their appointment; she under- went HIV testing and was reasonably engaged in the visit. Her partner took photos during the ultrasound and seemed happy about the preg- nancy. That is leaps and bounds beyond what she has done in her prior pregnancies. We will see where it leads. That will be the adventure. Fortunately, not all of our cases are as challenging as this one. At the other end of the spectrum, we have women who are diagnosed and on ARVs. The HIV component of prenatal care is straight for- ward and they have a completely beautiful and normal pregnancy, with their HIV diagnosis just one minor point of their pregnancy. I see a huge range of realities.

SPERM WASHING

The ideal is when a serodiscordant couple comes to us for precon- ception counseling, wanting to know how to reduce the risk of HIV transmission while trying to conceive. Those with HIV have fertility desires the same as the general population.

But how can they do that safely?

If the woman is the positive partner, there are some low tech ways of getting her pregnant without risking transmission of HIV to her partner. By using an ovulation predictor kit and having the male part- ner ejaculate into a cup or a spermicidal-free condom, they can do home insemination and he is at zero risk of acquiring HIV. The tricky situation is when he's positive and she's negative. HIV does not live in sperm, but it can in semen. One option is sperm wash- ingseparating the sperm from the other components of the semen. Then the woman is inseminated via intrauterine insemination (IUI), in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

Until Jan. 2008, it was illegal for us to offer sperm washing in Cali- fornia because of a 1989 law that prohibited the use of sperm from an HIV positive individual for artificial insemination, even if that person was the partner or spouse.

I served as medical advisor to the California state senator who sponsored legislation to make sperm washing possible. It was sup- ported by our survey of fertility clinics which found that a high pro- portion of California fertility clinics would be willing to offer services to serodiscordant couples if the law were to change. California re- versed the ban and now there are several clinics in California offering sperm washing with assisted reproduction. Sperm washing also is an option in several other states nation- wide for serodiscordant couples, but it can be expensive and not logistically possible for some. One possible intervention for them is periconceptional PrEP, or "PrEP-ception" as I like to call itthe uninfected woman would take PrEP during ovulation and following unprotected, timed intercourse.

There is a lot of interest in this, but the FEM-PrEP study was prematurely halted because Truvada was not found to be protective against HIV among female participants. There is no obvious biologic reason why PrEP would be effective among MSM but not women. I suspect adherence to the study drug may have played a role in FEM- PrEP, as a high proportion of participants, particularly those taking oral contraception, became pregnant and came off study drug. Last year, CAPRISA found a significant reduction in HIV acquisition among women using peri-coital tenofovir gel. Perhaps gel is better than oral PrEP for women. There are many unanswered questions and we anxiously await final FEM-PrEP results, as well as those from other trials such as VOICE. But it has made us pause as to whether PrEP-ception can be used for these couples

Challenges, Some Deadly

A lot of the women we see have phenomenal psychosocial challeng- es. That's the complicated part of helping them with adherence in midst of a chaotic life.

There is another, sometimes deadly, challenge. Many women, once the baby is born, stop caring for their own health, including HIV. Unfortunately, adherence commonly drops off dramatically postpartum. During pregnancy, they have a tangible goal of staying on their meds and not transmitting HIV, but once the baby is born their motivation drops dramatically. We have had several women who died of HIV-related complications because they were just unable to take their ARVs post- partum. Many of these women have not disclosed their HIV status to people around them. Some are homeless, so taking meds is not a top priority. For some, it's drug use. I just went to the funeral of one such pa- tient who was perinatally-infected herself. Her baby was negative, but she could not continue her ARV adherence after delivery. There were also cognitive issues; she struggled despite us trying to optimize all of the social services for her. Her funeral offered a sense of what we are up against. Some people there were actively us- ing drugs. She had a broken social network and did not disclose her status to most of her relatives. Once I saw her community, it was easier to under- stand why we were unable to meet her needs after her baby was born. Her baby is now 16 months old and being cared for by her HIV-negative sister. Today during BAPAC conference we talked about the most difficult patients first and ended on a positive note. There is a lot of burnout for people who do this work. I also attend on Labor and Delivery and get to participate in loads of normal, beauti- ful, healthy birthsthat is a nice reprieve. Despite the challenges confronted by many of my patients, they are the face of resilience. Most are also exceptionally committed to trying their best to have a healthy pregnancy. For many, pregnancy is the first time in their lives they are able to adhere to their antiretroviral medi- cation, minimize drug use, and engage with a healthcare provider. The key challenge is capitalizing on these successes and helping women continue with these healthy behaviors after delivery, help- ing them prevent HIV transmission to their babies and live healthy, productive lives. We encourage our women to not only envision hav- ing an HIV-uninfected baby, but attending their grandchildren's high school graduation.

aBout tHe autHor: Deborah Cohan, md, mph, aahivS, is associate professor in the department of obstetrics, Gynecology and reproductive Sciences at university of California, San francisco. She is medical director of bay area perinatal aidS Center (bapaC) and is associate director of the National hiv perinatal hotline and Clinician's Network, and assistant director of the uCSf fellowship in reproductive infectious diseases. She is a member of the dhhS panel on antiretroviral Guidelines for adults and adolescents.



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