Draft UK guidance on fertility treatment says that sperm washing may no longer be necessary for couples where the man has HIV and the woman does not. As long as the man is on effective antiretroviral treatment and unprotected sex is limited to days when his partner is ovulating, “sperm washing may not further reduce the risk of infection.”
On the other hand, the guidance does not support the use of pre-exposure prophylaxis (PrEP) by the HIV-negative partner.
The National Institute for Health and Clinical Excellence (NICE) is an influential body which issues recommendations to the NHS about the most effective and cost-effective treatments to provide. Their draft guidance on fertility treatments – an update to a document previously issued in 2004 – was issued today and is open for consultation.
As in the previous version, people with HIV are not excluded from access to fertility treatments, such as intrauterine insemination (IUI) or in vitro fertilisation (IVF). Moreover, the authors have removed a previous recommendation that the implications of the parent’s HIV infection for the child’s welfare “should be taken into account”.
The writing group reviewed in detail the scientific evidence for different methods that a couple could use to become pregnant, where the man has HIV and the woman does not. Previous guidance recommended sperm washing, but the experts also looked at the evidence for effective antiretroviral treatment and for pre-exposure prophylaxis.
“The evidence showed that whilst sperm washing did not appear to completely eliminate the virus in the semen on the basis of post-wash testing of prepared semen, the procedure appears to be very effective in reducing viral transmission in that no cases of seroconversion of the woman or the baby has been documented,” they found.
On the other hand, sperm washing has the disadvantage of reducing the likelihood of pregnancy occurring.
Moreover, the writing group identified effective HIV treatment as an alternative “which is equally effective, less invasive and more cost effective”.
They propose a criteria, similar to that of the ‘Swiss statement’, to determine whether unprotected vaginal intercourse would be an appropriate way to conceive. All the following conditions should be met:
The authors insist that their recommendation is limited to the situation of a heterosexual couple wishing to conceive and who limit unprotected sex to days when the female partner is fertile (ovulating). The authors have not provided guidance that is relevant to the risk of HIV transmission in other circumstances: “The context of this recommendation should not be extrapolated away from this remit,” they say.
Should the man have problems with adherence to antiretroviral therapy or were his plasma viral load to be detectable, the guidance recommends that his seminal viral load be tested. If HIV is undetectable in semen, doctors should inform the couple that the risk of HIV transmission during timed unprotected intercourse is “negligible”.
In situations other than these, sperm washing should still be recommended.
Moreover, the document acknowledges that some couples may still be anxious about the risk of HIV transmission during unprotected intercourse when the male partner is on effective treatment. In such a case, sperm washing would still be considered.
In terms of pre-exposure prophylaxis (PrEP), the experts looked at whether, for a couple in which the HIV-positive man was on effective treatment, there would be an additional benefit for his HIV-negative female partner in taking PrEP. They found only two studies in peer-reviewed journals that shed light on the question and that this evidence did not support the use of PrEP.
Consultation is open until 3 July.
Further information on the consultation can be found here. For details of the evidence on sperm washing examined by NICE, see pages 105 to 122 of the "full guidance" document (pdf).
