Can't HIV Serodiscordant Couples Now Just Have Children the Regular Way?

MMWR just published a paper entitled, Strategies for Preventing HIV Infection Among HIV-Uninfected Women Attempting Conception with HIV-Infected Men -- United States, and it's both a welcome and a very strange document indeed.

It's welcome because it acknowledges that serodiscordant couples may wish to have children without the use of an HIV-negative sperm donor. Advances in HIV prevention mean they can drop their categorical recommendation against insemination with semen from HIV-infected men, one they originally made in 1990.

But it's strange because, right alongside treatment of the HIV-positive man with antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) for the woman, is a fairly lengthy data summary on "sperm washing", a strategy many would argue has outlived its usefulness.

This is the short version of the procedure:

Another strategy that can be used in conjunction with HAART and PrEP is collection and washing of the male partner's sperm to remove cells infected with HIV, followed by testing to confirm the absence of HIV prior to intrauterine insemination (IUI) of the female partner or in vitro fertilization (IVF).

Does one really need to put couples through this expensive and time-consuming process when the risk of transmission is unmeasurably tiny, if not zero, if the man is on suppressive ART and the woman is taking PrEP? Can you imagine the number needed to treat to prevent one additional case of HIV transmission with sperm washing in addition to ART and PrEP?

It's like wearing a belt, suspenders, and using duct tape to keep your pants up (which is probably not the best analogy when discussing something that has to do with sex, but I'm going with it).

As a quick reminder:

  • HPTN 052: Zero transmissions from infected partner if HIV RNA suppressed.
  • PARTNERS Study: Zero transmissions from infected partner if HIV RNA suppressed -- this while the couples were practicing "condomless sex" (otherwise they couldn't be part of the study).
  • PrEP Studies: Among adherent participants, > 90% efficacy despite high risk behavior or high community risk.

Now we don't want to tempt the Gods of Never Say Zero with hubris about this unmeasurably low risk, but I clearly wasn't the only one who found the paper's emphasis on sperm washing peculiar.

Here's a take from Ben Young, Senior Vice President/Chief Medical Officer of the International Association of Providers of AIDS Care:

("U=U" stands for "undetectable equals uninfectious".)

Just for fun, I thought I'd check in with Pietro Vernazza, architect of the 2008 controversial "Swiss Statement" that has, for the record, turned out to be 100% correct.

Here was his response:

I was shocked about the report. In Switzerland, we have not seen any new infections among couples trying to conceive without using any additional safeguards (aside from treatment of the infected partner). The Swiss statement is very widely accepted.

And then, because what the hell, we deserve it, he added this:

But what should we say? We also don't understand how a country can withdraw from the Paris agreement, or try to build a wall to Mexico, or to withdraw health insurance for their citizens.

Hey, I'm a huge fan of our CDC, this odd report notwithstanding. But on these issues, you'll get no defense from me!

And just curious -- is there anyone out there still strongly advocating sperm washing for serodiscordant couples wanting to have children?