1. Introduction to HIV Discordant Couple Insemination Deborah J. Anderson, Ph.D. Dept Medicine and Center for AIDS Research Harvard Medical School and Department of Obstetrics & Gynecology Boston University School of Medicine Boston, MA

2. 1987 HIV/AIDS: a poorly understood lethal sexually transmitted disease Stewart et. (1985): seroconversion in 4 women following AI with semen from an HIV+ donor Published reports of HIV attachment to sperm High fetal maternal transmission rate

6. Dr. Enrico Semprini proposed to establish a protocol to reduce the risk of HIV transmission in HIV-1 discordant couples desiring a child

7. Gradient Sperm Separation Method Seminal Plasma 47% Separation Medium 90% Separation Medium Motile Sperm Nonmotile Sperm, Immature Germ Cells WBCs Discontinuous Density Gradient HIV p24 ++++ ++ +/-

8. Swim-up Method Swim-up Motile Sperm for Insemination Sperm Wash Medium Swim-up HIV p24 +/- ++

9. Gradient/Swim-up Method Swim-up Wash Pellet Seminal Plasma 47% Separation Medium 90% Separation Medium Motile Sperm Nonmotile Sperm, Immature Germ Cells WBCs HIV p24 undetectable

10. Additional elements in Semprini protocol: Reduce exposure by maximizing fertility and optimal timing of fertilization Reduce transmission risk by treating STDs and reducing HIV viral load

11. 1990 Chiasson MA, Stoneburner RL, et al. Human Immunodeficiency Type 1 virus transmission through artificial insemination. JAIDS 3:69-72, 1990 131 women in New York inseminated with fresh semen from 6 HIV+ donors. One seroconverted.

12. Centers for Disease Control. HIV-1 infection and artificial insemination with processed sperm. MMWR 39: 249-56, 1990. Recommendation: Do not used processed semen from HIV+ donors for artificial insemination 1990

13. Semprini AE, Levi-Setti P, Bozzo M, Ravizza M, Pardi G. Insemination of HIV-negative women with processed semen of HIV-positive partners. Lancet 340:1317-9, 1992. 1992

14. 1993 American Society for Reproductive Medicine Guidelines: ART services should be withheld from HIV-infected individuals or couples. Fertility and Sterility 59 (Suppl 1): 1-39, 1993.

15. 1997 Mandelbrot L, Heard I, et al. Natural conception in HIV-negative women with HIV infected partners. Lancet 349:850-1; 1997. 5% seroconversion rate in 92 HIV- discordant couples that practiced unprotected intercourse to conceive a child.

16. 1998 Marina S, et al. Human immunodeficiency virus type-1 serodiscordant couples can bear healthy children after undergoing intrauterine insemination. Fertil. Steril. 70: 35-39, 1998.

17. 2000 CreaThe is established: a consortium of 11 clinics in Europe that provide assisted reproductive technology services to HIV-1 infected couples. Forum for discussion Guidelines and protocols European database

18. 2002 Antiretroviral therapy has changed the perception of HIV-1 disease (chronic but manageable) and reduced the maternal-fetal transmission rate to <5%. HIV-1 infected individuals protected against medical discrimination by the Americans with disability act.

19. 2002 Recommendations of the ASRM Ethics Committee on Human Immunodeficiency Virus and Infertility Treatment. Fertility and Sterility 77: 218-222, 2002. Fertility services cannot be reasonably withheld from individuals with chronic viral infections including HIV-1.

20. Sauer MV. Providing fertility care to those with HIV: time to re-examine healthcare policy. AJOB 2003; 3: 3-40. ICSI procedure for insemination with HIV+ sperm US Experience

22. Resource Poor Settings Should timed inseminations be recommended for HIV discordant couples that want to have children? Fertility work-up Treatment of STIs Under development: sperm-friendly vaginal microbicides.