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In S.Paolo Hospital Healthy Children from HIV+ Fathers
An interview with Dr. Enrico Semprini, Ospedale San Paolo, Milan
How did you come to refine this method?
In 1985 we started a study to evaluate the possibility of removing the infecting component from the ejaculate of HIV males for reproduction purposes. The
trigger came from a request of a Padua's couple who asked us whether it was possible to conceive a child without risking a sexual "transfer" of the virus. Since sexual transmission of HIV was been by then already discovered, we
asked ourselves "where is the virus in the ejaculate" and "how much is it"?
Meanwhile, I sent one of my biologist to an Harvard laboratory for spermatic physiology. She was committed to replicate the same experiments and then evaluate the actual possibility of removing the virus without damaging the fertility. Both results of the studies, which we progressively communicated to scientific community, and the continuous pushings from numerous serodiscordant couples, which were ready even to stop using condoms to achieve a pregnancy, induced us to experiment a conception attempt via insemination. Of course, all
involved couples were perfectly informed of the limits of our knowledges.
Which reactions occured?
Our initiative was explosive and very difficult to face as well from an ethical viewpoint, taking into account also the attitude of the common opinion toward
HIV+ people. The major accusation, coming also from the scientific community, was that we were building an "orphans factory". The reality is, and this has been well known since years, that HIV+ people have today a better life prognosis than individuals of the same age hit by cancer. If a person suffering by cancer
showing no recidive symptoms would express the wish to have a child, everybody will accept it with relief because it would mean that that person is able to build himself a future and does not think only of the disease. Instead, in the same situation an HIV+ individual receives a completely opposite message, even if the survival expectation is exactly the same.
What is your position about it?
We never did any kind of discrimination, since we consider HIV as an infective disease just like other pathogenics which complicate life of humans. The behaviour of the physicians facing the infective diseases has always been only one: try and isolate, identify and fight them. We are experts in reproduction, thus we did with HIV just what is expected from us. HIV is tightly connected
with reproduction: on one hand there is the sexual transmission, on the other hand the transfer of the virus from the mother to the child.
Three years after the first insemination, and after 59 couples submitted to us, "The Lancet", one of the most prestigious international medical publications, accepted to publish our article, announcing it to the press in advance with the title "HEALTHY CHILDREN FROM HIV+ FATHERS". This had a big emotional impact, most of all considering that the main transmission way in the world is heterosexual intercourse. Even if at least so far this is not the prevailing way neither in Italy nor in USA, nevertheless heterosexual transmission is rapidly increasing.
There is a huge number of heterosexual HIV+ males, infected as a consequence of drug addiction, that after stop using drug met a seronegative woman. In most serodiscordant couples the man is the one to be affected by HIV. In our opinion ignore this reality is a big mistake from an health policy respect. Epidemic data show that heterosexual infection is increasing and three cases out of four concern women. We do think that the use of condom can be strongly endorsed if we manage to send the message that if a woman remains seronegative she still can become mother of an healthy, non infected child, and stand by him/her if the HIV-disease of her partner takes a bad course. We observed that the couples followed by us (and normally living together since long time) after the insemination use condoms normally, and no woman seroconverted.
Which is the procedure to follow?
Simply call S.Paolo Hospital in Milan (+39 2 89.12.99.79); two afternoons in a week physicians are available to answer the phone. After that we send four informative sheets. The first sheet describe the features of our program. The second sheet lists all the tests required to exclude that neither partner suffers for fertility problems. This is necessary because the use of condom, that allows the couple to remain serodiscordant, prevents to discover these problems. It is also useful to check that the woman's tubas are open, that the level of spermatozoa of the man is adequate (HIV itself or some HIV treatments may compromise the semen quality) and that there are no genital infections or other infections such as B- or C-hepatitis. It has to be noted that 30% men are affected by genital infections facilitating HIV transmission.
Can also the hepatitis virus be "washed away" from sperm?
A vaccination exists agains B-hepatitis. About C-hepatitis, no negative woman with positive man seroconverted. Currently, a very good biologist of our team is working in Paris at Pasteur Institute. She is completing a collection of data showing that C-hepatitis virus may be found only in the seminal plasma component that is washed away in our method, and it is inhibited by a substance degrading its RNA. Noone of the women followed by us has ever infected, regardless of transaminase level of the man and of the fact that he was affected by an active or highly-replicating hepatitis.
Is low CD4-cells count and/or high viral load an obstacle?
No. We have always been against any selection excluding people with a low CD4 count or at an advanced disease stage, even if the viral load is high or PCP (Pneumocystis Carinii pneumonia) or other opportunistic diseases already showed up. Selecting would mean take a decision on their behalf, substituting for someone more important, and set a requirement in life expectation or general health as a condition for an individual to be a good parent. Besides, do not forget that a couple could always give up using condoms and look for a natural pregnancy. This is precisely what we are trying to avoid. What we are saying to the couples is, "if your wish is to become parents, we are here to help you to keep things under control".
Are there any data available?
They are listed in the third sheet that we send to couples. So far, we performed almost 800 inseminations in 250 women. No seroconversions were observed. Average 19% inseminations are successful. About half of the women were fertile enough, or we restored a good fertility, and they conceived at the first attempt. Officialy, about 90 children have born but it is likely that we are close to the hundredth birdth, because sometimes couples are so happy that they forget to notice us. Available data are rounded by defect.
The fourth sheet requires the so called "informed consent". The couple is clearly informed that:
- everything is done from a laboratory respect to assure safety as highest as possible;
- all studies, regardless of the method used, always showed that the final product used for insemination is deprived of viral infecting component;
- no methods exist to identify even single viral couples and the exact sexual transmission mechanism of HIV is not completely known.
Fortunately, in our casistic, by now big enough, the infection never happened. However, it is better to take into account a minimum risk of infection and compare it to the importance to the couple to have a child. On one hand, if it is true that no riskless medical methods exist (even vaccination has its risks), on the other hand HIV virus has a severe prognosis, and we think it is correct that a couple be informed and decide autonomously.
Whom is this service available for?
So far, the method has been applied to a considerable number of couples. The service is open to Italy and to the rest of the world. 10% couples are not Italian and 70% come from outside Lombardy. A couple in Pasadena and another one in New York decided to have a second child after having the first one with us. They are now waiting for the birdth of a little girl.
Are you the only ones to follow this technique?
Yes, we are the only ones in the world. We refined the method and we are the only ones with a program that is simple and complex at the same time, from a technological and assistance respect as well from an ethical and political one. People coming from USA are mostly hemophilic, infected by blood transfusions, while there are no former drug addicted people, like if there was a kind of
self-selection between "good" and "bad". On the opposite, in Italy hemophilic people are only two against hundred former drug addicted.
What is your position on drug addiction?
We require that drug have been definitively abandoned. This is the only not strictly medical selection. We are against operating controls; the talk with us is also a statement from the couple that drug consumption has definitively ended and it belongs to the past. This is a way to make people consider that drug and children are mismatching.
How large is the team?
We are about twenty experts. Since our organization structure is complex, we are working in turnover. Our team includes a molecular biologist, two experts in sperma treatment and several experts in assisted fecundation methods. As far as I am concerned, I studied obstetrics, gynaecology and reproduction immunology and I am now specializing in infectious diseases. Our team is a composite one that collects different competences for a single program.
The support from S.Paolo Hospital and the University Medical Center has been total. It is rather more difficult to obtain funds from Rome, but this can be easily understood if we consider the controversies related to HIV. We are for sure pioneers in dealing with a problem that will assume huge dimensions in the future. When the prognosis will be twenty years starting from the infection, how would it be possible to say to a 32-year HIV man "you can not have a child of your own" when the risk to infect the woman is one against 5000? Becoming father has also an important impact on HIV disease. NO ONE OF OUR FATHERS IS DEAD. Of course, it is very difficult to prove that the only reason for that is the parentship, also because HIV treatments have changed. Still, I am convinced that these couples go over an evolution, like any other couple when a child arrives. A different world is opening in front of them, they have new responsibilities. The need to stay healthy is no longer individual but takes also a projective value. After all, all long term survivors have a specific psychological capability: they are positive people, with a choice for a very "physiologic" lifestyle. They care for their nutrition, eliminate all possible toxic substances, increase sleeping time, sometimes perform meditation. What I mean is that there is a pshycological way to react to HIV and this is not to be neglected because it is very important. Our program proposes itself not as an antagonist but rather as a parallel way to a particular choice of life quality.
| Dr. Semprini and the other members of his staff are available to provide further information on this technique. You can contact them on Tuesday and on Thursday, from 2 P.M. to 5 P.M., Italy time, calling at the number +39 2 89.12.99.79.
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