Should HIV discordant couples have access to assisted reproductive technologies?(HIV And Assisted Reproductive Technologies)

People infected with human immunodeficiency virus (HIV) are living longer and experiencing improved health. Substantial advancements in treatment mean that from the time of diagnosis, an adult infected with HIV who has access to treatment, can expect to live for "at least 20 years". (1 2) The prospect of better health and increased life expectancy means that the idea of becoming a parent is not out of the question and some people with HIV want children. And they want access to assisted reproductive technologies (ART) which may reduce the risk of transmission to uninfected partners and offspring.

Heterosexual transmission of the virus is low, but a risk does exist. For HIV discordant couples where the male partner is positive and the woman is negative, a technique known as "sperm washing" is a way to further reduce the risk of transmission. The technique, pioneered by Augusto Semprini in Milan, involves the "washing" of semen to remove everything but the actual spermatozoa. (3) After washing, the sperm can be combined with ova from the female partner using in vitro fertilisation (IVF) techniques or direct injection of the sperm into a selected oocyte--intracytoplasmic sperm injection (ICSI). Since the technique has been offered, three hundred children have been born with no reports of seroconversions in children or uninfected partners. (1)

Sperm washing with IVF or ICSI is routinely offered by centres in Italy and Spain, along with some other places. (1 4) It is not readily available in the United States. In 1990 in Virginia, a woman seroconverted after being inseminated with her husband's sperm. No pregnancy resulted and while it has not been proven that it was the insemination techniques that caused the infection, the US Center for Disease Control has been reluctant to support future trials until the procedure can be proved safe. (1 5 6) In Melbourne, Australia, a hospital has recently decided to offer the procedure. In the past, Australian reproductive services have treated HIV discordant couples with artificial insemination using sperm from HIV negative male donors. But using donor sperm is not acceptable to some couples who want to have their own children. (4) The Melbourne Hospital has now developed a protocol for the treatment of HIV discordant couples using their own gametes. (7)

THE ISSUES

Safety and public health considerations figure prominently in the debate about offering ART to HIV discordant couples. The welfare of the child, prevention of harm, issues of discrimination, acceptable levels of risk, and the obligations of health care professionals also figure. Offering ART to HIV discordant couples raises questions such as: what is an acceptable level of risk to offspring and should couples who want this assistance be subject to selection criteria? Should they undergo scrutiny about their suitability as parents when those who are able to conceive naturally face no such scrutiny and people with other illnesses are given access to ART? It also raises the question of whether HIV differs in any morally significant way from other illnesses or conditions. Is it worse for a child to be born to a parent who is HIV positive than to a parent with some other condition?

In this paper we identify and evaluate the arguments for and against offering assisted reproductive technologies, specifically IVF, to HIV discordant couples. We also identify additional considerations of ethical relevance.

ARGUMENTS AGAINST OFFERING ART TO HIV DISCORDANT COUPLES

Safety and public health considerations

Safety and public health considerations form the basis of an argument against offering assisted reproductive technology to HIV discordant couples. The risk of transmitting the virus to an uninfected partner and to the resulting child is a major problem. This has led some people to the view that HIV positive people should not have children, because the magnitude of the risk, despite the low transmission rate, is too great to take. They think it is morally wrong to knowingly conceive a child under these circumstances. Even with improved prognosis and treatments, acquiring the disease is still a disaster.

Given that these objections exist, it is obvious that there will be objections to offering assisted reproductive technologies to someone who is HIV …