The right to become a mother without getting HIV

the results of a study from the Carlos III Hospital (Spain) on the transmission of HIV in serodiscordant couples (couples where only one of the two members is HIV-positive) willing to have children, were made public.

The conclusions from the Spanish investigators were the following: ”unprotected sexual relations during a woman’s fertile period may be considered as an alternative to in vitro conception for serodiscordant couples who wish to be parents.“ This statement inspired the Spanish press to treat this extremely complicated subject in a totally hair-rising way, creating hope and confusion in serodiscordant couples and the general population as well, in regards to risky practices and unprotected sex. In Spain, assisted reproduction techniques are expensive and at the cost of the couples.

To put things back into context, it is not the first study of this type to be conducted. Probably the most known is a French investigation that took place in 1997 and enrolled 92 serodiscordant couples in which it was the male who was HIV-positive. In this study four women seroconverted to HIV: two during the first trimester of pregnancy and two after the birth. It was suggested that these infections occurred because couples did not follow the recommendations to use condoms once the woman got pregnant. In general, this study and others of similar characteristics show (but do not prove) that in serodiscordant couples who attempt conception through unprotected sexual relationships, using condoms the rest of the time, the risk of transmission was reduced (but not eliminated).

What is particular to this new study is that it takes place at a time when the use of Highly Active Antiretroviral Therapy (HAART) is generalized, and that it also includes couples in which it is the woman who is living with HIV. However, it seems extremely difficult to compare couples in which in some cases it is the man who is HIV-positive and in others the woman, above all knowing that through vaginal intercourse and given their intimate anatomy, women are more at risk biologically to get infected by sexual route than men. Despite this, one of the conclusions of the Spanish investigators was that there were no ”significant differences“ according to whom of the two members was infected.

Another controversial aspect is that this observational study all started when the investigators received serodiscordant couples in their practice who wished to become parents but did not want to (or could not for economical reasons) go through assisted reproduction methods such as sperm washing. They decided to start a study with 75 couples who, instead of being helped to have access to these techniques that are known to be safe, were given recommendations –to wait up to six months after achieving viral loads below 50 copies/ml with HAART to have unprotected sexual intercourse and to limit it to during the women’s fertile days. Couples were then followed-up and the investigators collected information regarding conception and the transmission of HIV. The study was presented as successful, with the birth of 76 HIV-negative infants, and no mother being infected.

Besides the fact that this observational procedure does not require scientific skills, it offers results that would need to be contrasted by some essential aspects. For instance, how many times did the couples attempt conception before achieving it? How many women experienced miscarriages? Indeed, to present the study in terms of 75 couples = 76 children can lead to false expectations within these couples on how easy it is to get pregnant following these recommendations.

In many publications following this trial’s results, it was not rare to see declarations such as: ”An efficient antiretroviral treatment will allow serodiscordant couples to have healthy children and at the same time not transmit the virus to their partner.“ Most of the media announced that this ”discovery“ represented a ”great hope“ for serodiscordant couples. That this ”strategy“ could now replace assisted reproduction methods such as sperm washing or in vitro fertilization, that supposedly cost so much to the public health system in the countries where they are indeed covered by such system, and to the couples themselves in other countries like Spain where they are the ones who must pay for it. In Spain again, this result comes at the same time as the publication of a report by the Catalan Agency for the Assessment of Medical Technology and Investigation ordered by the HIV/AIDS prevention and assistance Program of the Catalan Health Department. This report declared that the introduction of sperm washing techniques in the public health system could represent an ”ethical dilemma“ given its elevated cost and in comparison to the benefit that it could mean for serodiscordant couples to have natural children. One can easily foresee what type of impact this report along with these new results by the Carlos III Hospital, could have on future efforts to make these techniques available for free to people who need them in this country. What will it be for the rest of Europe and above all countries where they are already offered at no cost for HIV serodiscordant couples? In the whole world women still constitute the population that is most affected by sexual transmission of HIV. This new study and its conclusions show once more how much it is overlooked that women do not only have reproductive but also sexual rights and the right to life. Not like in other much more disadvantaged countries, in this part of the world we have the great privilege to benefit from assisted reproduction techniques that reduce down to almost none the risk that child and mother get infected. Who will put them within our reach?

References

1. AUGUSTO E. SEMPRINI, SIMONA FIORE, GIORGIO PARDI: Reproductive counselling for HIV-discordant couples, Department of Obstetrics and Gynaecology, San Paolo Biomedical Institute, University of Milan Medical School, 20142 Milan, Italy. The Lancet Volume 349, Number 9062.
2. AUGUSTO E SEMPRINI, SIMONA FIORE: ”HIV and reproduction“, Current Opinion in Obstetrics & Gynecology, 16(3):257-262, June 2004.
3. J. T. WILDE: Conception in HIVdiscordant couples, West Midlands Region Adult Haemohilia Centre, University Hospital Birmingham NHS Trust, UK. Treatment of Hemophilia May 2002, nº. 26.
4. PABLO BARREIRO, VINCENT SORIANO, MARINA NÚÑEZ, JUAN GONZÁLEZ-LAHOZ: Benefit of antiretroviral therapy for serodiscordant coupes willing to be parents, Infectious Diseases, Hospital Carlos III, Madrid, Spain.

Marion Zibelli

EATN - European AIDS Treatment News, Volume 13, I – Spring 2005

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