CDC reviews HIV prevention strategies among discordant couples attempting conception

Issue: July 2017

Since the CDC first recommended against insemination using semen from men with HIV in 1988, new evidence has emerged regarding HIV transmission among discordant couples attempting conception, according to a recent MMWR.

Although insemination with sperm from a donor without HIV remains the safest option for an uninfected woman to conceive, Jennifer F. Kawwass, MD, of the CDC’s Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, and colleagues said the risk for transmission from a man with HIV to an uninfected woman is low when proper risk-reduction strategies are implemented.

According to the researchers, one risk-reduction strategy is condomless intercourse with the use of highly active ART (HAART) and daily pre-exposure prophylaxis (PrEP) limited to the time of ovulation. They reported that the risk for transmission from a man on HAART with undetectable seminal and plasma viral loads to an uninfected woman is 0.16 per 10,000 exposures (95% CI, 0.02-1.3). However, although some studies demonstrate a parallel reduction in plasma and semen viral loads, other evidence suggests there is no correlation. Therefore, men on HAART with undetectable plasma loads may have a “very low” (1.2 per 100 person-years; 95% CI, 0.9-1.7) risk for transmitting HIV, the researchers wrote.

Another risk-reduction strategy involves sperm washing before intrauterine insemination (IUI) or in vitro fertilization (IVF). The process involves gradient centrifugation and separation of sperm from semen, followed by use of a lymphocyte preparation medium that separates sperm from lymphocytes — the largest HIV reservoir in semen. HIV RNA testing of washed specimens indicate that 92% to 99% of specimens contain no measurable viral loads.

“Testing the resultant specimen for presence of residual HIV before insemination can identify 1.3% to 7.7% of specimens that have been noted to be positive after appropriate washing,” Kawwass and colleagues wrote. “These 1.3% to 7.7% of washed specimens that test positive even after washing would be discarded and not used for insemination.”

There are approximately 11,500 instances where women without HIV underwent IUI or in IVF using washed sperm from their partners with HIV and did not contract the virus. Further, no transmissions were reported among infants born to these mothers. Although there have been reports of women becoming infected after IUI, evidence suggests the infections were contracted from subsequent condomless intercourse.

The risk for transmission per IVF cycle is estimated to be similar to the risk per IUI cycle, according to the researchers. However, IVF is more effective than IUI or natural conception. Therefore, the cumulative risk may be lower with IVF because the number of exposures to sperm from a man with HIV may be fewer. Despite this, it is unknown whether the cumulative risk-reduction benefit of IVF compared with IUI might offset the surgical risk and financial cost of IVF if it is not being used as infertility treatment, the researchers wrote. The risk associated with either procedure can be further reduced with the use of HAART and PrEP, they added.

“As data regarding the safety and effectiveness of semen processing emerge, the risk profile for each treatment option will be further defined,” Kawwass and colleagues concluded. “HIV–discordant couples who desire to conceive might wish to discuss treatment options with a medical provider who can explain the risks and benefits of different treatment modalities as they apply to the couple’s specific situation before attempting conception.” – by Stephanie Viguers

Reference:

Kawwass JF, et al. MMWR Morb Mortal Wkly Rep. 2017;doi:10.15585/mmwr.mm6621a2.

Disclosure: The researchers report no relevant financial disclosures.