i simposio internacional de reproduccion y hiv
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I SIMPOSIO INTERNACIONAL de REPRODUCCION y HIV. CONCEPTS AND DATA FOR THE PRESS Dr Augusto E Semprini University of Milan & University College of London Dr Sergio Pasqualini Halitus Instituto Medico. The Problem: HIV in Semen. SEXUAL TRANSMISSION OF HIV. Sexual contact. -. +. - PowerPoint PPT PresentationTRANSCRIPT
I SIMPOSIO INTERNACIONAL I SIMPOSIO INTERNACIONAL de REPRODUCCION y HIVde REPRODUCCION y HIV
CONCEPTS AND DATA FOR THE PRESSCONCEPTS AND DATA FOR THE PRESS
Dr Augusto E SempriniDr Augusto E SempriniUniversity of Milan & University College of LondonUniversity of Milan & University College of London
Dr Sergio PasqualiniDr Sergio PasqualiniHalitus Instituto MedicoHalitus Instituto Medico
The Problem: HIV in Semen
SEXUAL TRANSMISSION OF HIVSEXUAL TRANSMISSION OF HIV
+ -InfectivityInfectivity
Sexual contactSexual contact
SusceptibilitySusceptibility
DISCLOSURE OF HIV DISCLOSURE OF HIV INFECTION DIAGNOSISINFECTION DIAGNOSIS
FEARS OF:
•DISABILITY AND DEATH
•SOCIAL OUTCASTING
•PROBLEMS WITH PROFESSIONAL LIFE
•LIMITATIONS IN PERSONAL LIFE
•BEING UNABLE TO HAVE A HEALTHY CHILD
COUPLES WITH HIVCOUPLES WITH HIV•Man with HIV & uninfected woman
•Woman with HIV & uninfected man
•Both partners with HIV (same viral strain)
•Both partners with HIV (different viral strains)
REPRODUCTION AND HIVREPRODUCTION AND HIV
REPRODUCTIVE COUNSELLING
&
REPRODUCTIVE ASSISTANCE
EUROPE 2001EUROPE 2001•IN THE EU THERE ARE PROBABLY 250.000 TO 500.000
INDIVIDUALS AGED BETWEEN 19 AND 34 YEARS WHO
ARE INFECTED WITH HIV
•THERE MAY BE 200.000 TO 400.000 UNINFECTED
PARTNERS AT RISK OF SEXUAL ACQUISITION OF HIV
•ACCORDING TO THE RATE OF SEXUAL AND
VERTICAL TRANSMISSION, THERE MAY BE 30.000 TO
4.000 UNBORN INFANTS AT RISK OF ACQUISITION OF
HIV FROM THE INFECTED MOTHER
COUPLES WITH HIVCOUPLES WITH HIV•In Europe most cases of infection with HIV derive
from the use of intravenous drugs
•Drug use is a prevalently male behaviour (male to
female ratio 4/1)
•Most male drug users are heterosexual (> 95%)
•Young uninfected females are at risk of acquiring HIV
from these HIV-infected males
COUPLES WITH HIVCOUPLES WITH HIV
•Women at highest risk of sexual acquisition of HIV
are the habitual partners of HIV-infected males
•In Italy three out of four new cases of heterosexual
transmission of HIV are females
•Less than 50% of HIV-discordant couples regularly
recur to condom protected intercourse
•HIV-discordant couples should be motivated to
avoid any risk of infection for the healthy partner
ARE THE REPRODUCTIVE RIGHTS OF ARE THE REPRODUCTIVE RIGHTS OF PEOPLE INFECTED WITH HIV PEOPLE INFECTED WITH HIV
RESPECTED ?RESPECTED ?
THERE IS A NUMBER OF TRANSMISSIBILE
CONDITIONS THAT ARE NOT REGARDED AS A
REASON TO DISCOURAGE PROSPECTIVE PARENTS
OF POTENTIALLY AFFECTED CHILDREN FROM
TRYING FOR A PREGNANCY, IS IT THE SAME FOR
HIV ?
GOALS OF REPRODUCTIVE COUNSELLING TO HIV DISCORDANT COUPLES
•OFFER NON-JUDGMENTAL UNBIASED INFORMATION TO LIMIT THE RISK OF TRANSMITTING THE INFECTION TO THE UNINFECTED PARTNER AND TO THE INFANT•HELP TO REDUCE THE RISK OF TOXIC CONSEQUNECES OF ANTIRETROVIRAL THERAPY TO THE OFFSPRING
SECONDARY GOALS OF REPRODUCTIVE SECONDARY GOALS OF REPRODUCTIVE COUNSELLING TO HIV DISCORDANT COUNSELLING TO HIV DISCORDANT
COUPLESCOUPLES
•HELP THE INDIVIDUAL WITH HIV TO
ELABORATE ITS DESIRE OF PARENTHOOD
•REINFORCE THE BENEFITS OF AVODING
SEXUAL TRANSMISSION OF HIV TO THE
UNINFECTED PARTNER BEFORE AND
AFTER PREGNANCY
WHAT ABOUT WHAT ABOUT
REPRODUCTIVE REPRODUCTIVE
ASSISTANCE ?ASSISTANCE ?
REMOVAL OF p18 IMMUNOREACTIVE CELLS REMOVAL OF p18 IMMUNOREACTIVE CELLS FROM THE SEMEN OF HTLV-III/LAV FROM THE SEMEN OF HTLV-III/LAV SEROPOSITIVE MENSEROPOSITIVE MENAugusto E Semprini, A Vucetich, E Morandi, CL Parravicini, G Augusto E Semprini, A Vucetich, E Morandi, CL Parravicini, G Pardi and AE Beer. Colloque INSERM, Vol. 154, 1987, pp 462Pardi and AE Beer. Colloque INSERM, Vol. 154, 1987, pp 462
A cytospin preparation of washed spermatozoa, supernatant and the A cytospin preparation of washed spermatozoa, supernatant and the second fraction of the ejaculate were chloroform-acetone fixed and second fraction of the ejaculate were chloroform-acetone fixed and tested against a monoclonal anti-p18 antibody by immunoperoxidase tested against a monoclonal anti-p18 antibody by immunoperoxidase technique. Washed sperm of seropositive and seronegative men was technique. Washed sperm of seropositive and seronegative men was non-reactive, while many mononuclear cells and those in the second non-reactive, while many mononuclear cells and those in the second fraction of seropostive males were strongly reactive. fraction of seropostive males were strongly reactive. Experiments are Experiments are under way to test the possibility of safe intrauterine insemination under way to test the possibility of safe intrauterine insemination with processed semen of HIV-positive men desiring a child.with processed semen of HIV-positive men desiring a child.
l
45%
90%
Gradiente MigrationLavado
Wash,1/8 PCR
LAVADO DEL SEMENSemprini et al. The Lancet, 27 November 1992
Dilucion al final del procedimiento: 4 x 106
INSEMINATION OF HIV-NEGATIVE WOMEN WITH INSEMINATION OF HIV-NEGATIVE WOMEN WITH PROCESSED SEMEN OF HIV-POSITIVE PARTNERSPROCESSED SEMEN OF HIV-POSITIVE PARTNERS
85 HIV-discordant couples were screened for fertility; 29 women were found suitable for a timed insemination course with the processed semen of their HIV-positive partner. None of the inseminated women seroconverted and 17 pregnancies were achieved in 15 women. All 10 infants born to these mothers remain HIV seronegative.
(Semprini et al. - Lancet 1992; 340: 1317-19)
Insemination of HIV-negative women with Insemination of HIV-negative women with processed semen of HIV-positive partnersprocessed semen of HIV-positive partners (Brian R Edlin and Scott D Holmberg Lancet, February 27 1993)
Dr Semprini et al. (Lancet, November 1992) conclude that
the lack of HIV transmission during their artificial
insemination attempt in HIV-discordant couples is
“reassuring” and suggest that this outcome is used in
counselling such couples to “give them hope of having
healthy babies”. We are concerned that their conclusions
may be overstated and could mean that physicians may
provide false hope to such couples.
ETHICAL ASPECTS OF THE INSEMINATION OF HIV-NEGATIVE WOMEN WITH PROCESSED SEMEN OF
HIV-POSITIVE PARTNERSC. La Vecchia, Human Reproduction, Vol. III, n. 3, 1993
“Nowadays the ethical aspects of medicine are complex. It is surprising how this may lead to less stringent criteria for judgement of ethical aspects by the doctors themselves, who in some case may even disregard the basic principle that in no case the life of a healthy individual should be threatened by a medical intervention. An example of this uncertainty and confusion is a recent report of the utilisation of intrauterine insemination with processed semen of HIV-positive partners for HIV-negative women.”
SPECIAL CONSIDERATIONS REARDING HIV AND SPECIAL CONSIDERATIONS REARDING HIV AND ASSISTED REPRODUCTIVE TECHNOLOGIESASSISTED REPRODUCTIVE TECHNOLOGIES
AmericanAmerican Society for Reproductive MedicineSociety for Reproductive Medicine
Fertility and Sterility Vol. 62, No. 5, November 1994Fertility and Sterility Vol. 62, No. 5, November 1994
USE OF SEMEN FROM HIV-POSITIVE PARTNERS FOR USE OF SEMEN FROM HIV-POSITIVE PARTNERS FOR INSEMINATION OF SERONEGATIVE WOMEN PARTNERSINSEMINATION OF SERONEGATIVE WOMEN PARTNERS
“The Committee recommends that the “The Committee recommends that the physician counsel physician counsel the couple regarding the risks to the woman and the couple regarding the risks to the woman and
offspring through homologous insemination by any offspring through homologous insemination by any meansmeans and that the couple consider the options of donor and that the couple consider the options of donor
insemination, adoption, or child-free living.”insemination, adoption, or child-free living.”
SPECIAL CONSIDERATIONS REARDING HIV AND SPECIAL CONSIDERATIONS REARDING HIV AND ASSISTED REPRODUCTIVE TECHNOLOGIESASSISTED REPRODUCTIVE TECHNOLOGIES
AmericanAmerican Society for Reproductive MedicineSociety for Reproductive MedicineFertility and Sterility Vol. 62, No.5, November 1994Fertility and Sterility Vol. 62, No.5, November 1994
HIV TESTING FOR COUPLES CONTEMPLATING ARTHIV TESTING FOR COUPLES CONTEMPLATING ART
“While proceeding with ART after a positive HIV test “While proceeding with ART after a positive HIV test
is not necessarily unethical, is not necessarily unethical, the Commitee the Commitee
considers HIVconsiders HIV infection a serious contraindication to infection a serious contraindication to
treatmenttreatment””
Natural conception in HIV-negative women with Natural conception in HIV-negative women with HIV- infected partnersHIV- infected partnersL Mandelbrot, I Heard, E Henrion-Geant, R Henrion (Lancet 1997; 349: 850)
We followed 104 consecutive pregnancies in 92 HIV-negative women with HIV-positive partners. Couples were advised to pinpoint ovulation in order to reduce possible exposure. Seroconversion was observed in two women at 7 months of pregnancy and in two others post partum. Some authors advocate intrauterine insemination with semen from the HIV-infected males, but the risk of this must be measured against the low background risk of natural conception. Stringent standard of safety must be required before inseminating potentially infected semen.
PROBLEMS IN REPRODUCTIVE PROBLEMS IN REPRODUCTIVE ASSISTANCE TO COUPLES WITH HIVASSISTANCE TO COUPLES WITH HIV
•WHICH PROCESSING METHOD ?WHICH PROCESSING METHOD ?
•WHICH HIV TESTING FOR SPERMATOZOA?WHICH HIV TESTING FOR SPERMATOZOA?
•WHICH CENTERS FOR ASSISTANCE?WHICH CENTERS FOR ASSISTANCE?
•WHO PAYS ?WHO PAYS ?
•HOW TO TREAT FERTILE COUPLES ?HOW TO TREAT FERTILE COUPLES ?
•HOW TO TREAT INFERTILE COUPLES ?HOW TO TREAT INFERTILE COUPLES ?
•WHICH SEROLOGICAL FOLLOW-UP ?WHICH SEROLOGICAL FOLLOW-UP ?
A NETWORK OF CENTERS PROVIDING REPRODUCTIVE ASSISTANCE TO
COUPLES WITH HIV
•COMMUNICATION BETWEEN CENTERS
•EXCHANGE OF INFORMATION
•OPTIMIZATION OF RESOURCES
•MONITORING OF THE REPRODUCTIVE
DESIRE AND NEEDS OF INDIVIDUALS AND
COUPLES WITH HIV