Expert's Perspective

Assisted Reproductive Technologies For HIV-Positive Men

The world of Assisted Reproduction has been addressing the needs of HIV-positive men since 1989 and we’ve made major strides since then.

The story begins in Milan, Italy where the HIV population was mostly heterosexual men infected through previous intravenous drug use and who wanted to have children with their female partners. It was there that Dr. Augusto Semprini developed the technique of double washing sperm. In this procedure the semen sample was spun in a test tube pulling the sperm to the bottom. After the white seminal fluid on top was discarded, a bathing solution was added and the tube gently heated. The sperm then swam to the top and were collected for intrauterine insemination (IUI). In 1992 Dr. Semprini published a report of his first 29 cases and not one woman became infected with HIV.

Sperm washing is now a standard procedure for semen collection and below is the bottom line when the donor is HIV positive.

The last systemic review and meta-analysis of scientific reports in any language using sperm washing was published in 2016 and included 40 studies. It showed that no HIV transmission occurred among 3,994 women who collectively underwent over 11,000 ART cycles. This included IUI, and in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI).

That is an amazing statistic, but I want to give you more of the story and a view of the current landscape in ART for HIV-positive men, so read on.

Viral Load and RNA Detection

In 1989 there was no successful HIV treatment. The “three-drug cocktail” did not become available until late 1995, so in Milan all those men had HIV circulating in their blood. We know this because in 1995 a test called “viral load” became available, which enabled us to count the number of HIV particles in a patient’s blood.

Then if a person received the right three HIV medications, their viral load would fall to zero and stay there. But what we noticed next was that patients with undetectable viral loads did not seem to be infecting their partners.

This phenomenon became so widely observed that in 2008 the Swiss Federal HIV Commission issued the now famous “Swiss Statement.” It states that if a person has been on HIV medications without interruption and the viral load has remained undetectable for six months, they should be considered “sexually non-infectious,” (i.e. they cannot pass on HIV). While we can never say the risk is zero, other studies support the conclusion of the Swiss Statement.

Therefore many fertility clinics that work with HIV-positive men now require them to have undetectable viral loads as an extra precaution. (However, the meta-analysis I cited above included some studies with men who were not undetectable. These studies involved 1,023 women who had 2,863 cycles with washed sperm and no HIV transmission.)

In addition, we can now run HIV RNA detection on sperm samples to detect any remaining HIV particles.

In approximately 10% of samples from men with undetectable blood viral loads, low levels of HIV are still detectable in the semen. Remember these men are still non-infectious - probably because the virus in their semen is present in such small amounts or is not “fully competent.” Currently some fertility clinics will check every washed sample for HIV RNA. If any is found, which happens from 2 - 7% of the time, the clinic will discard that specific sample.

PrEP and Truvada

Finally, there is one other option to reduce the risk of HIV transmission. This is call PreP, or pre-exposure prophylaxis.

In 2012, a standard HIV medication called Truvada was approved by the FDA for use by HIV-negative people who are at-risk for exposure to HIV. Its use has been on the upswing and current data indicates it is close to 99% effective in preventing HIV transmission. Because Truvada is safe to use in first trimester pregnancy, some fertility clinics now give this to surrogates to take at the time of embryo transfer.

Much has happened since 1989, but the goal has always been to protect the health of the woman of the baby.