World AIDS Day 2023 How HIV Impacts Fertility Maternal Infant Outcomes When A Parent Is HIV Positive Treatment Options

Acquired Immune Deficiency Syndrome (AIDS), caused by the human immunodeficiency virus (HIV), can result in sub-fertility in patients due to biological alterations in reproductive physiology. Over 38 million worldwide are HIV-positive. HIV infection also affects psychosocial factors because of which reproductive desires are impacted. HIV is a retrovirus (contains reverse transcriptase, an enzyme which converts single-stranded RNA into DNA), and hence, is treated using antiretroviral medicine.  

Nucleoside analogue reverse transcriptase inhibitors (NRTIs) are a highly active antiretroviral therapy which has resulted in decreased risk of transmission of HIV from mother to child. 

However, antiretroviral medications are toxic to gametes and embryos.

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How HIV impacts fertility in women

According to a 2011 study published in the journal Fertility and Sterility, HIV-infected women in sub-Saharan Africa had 25 to 40 per cent lower fertility rates than uninfected controls, early research has shown. The study said that this was the first suggestion that HIV was linked with fertility defects. 

The reasons why sub-fertility is observed in HIV-infected women include biological alterations, systemic illness, weight loss, stress, and drug abuse. HIV-infected women often have anovulation (egg is not released from the ovary during a menstrual cycle) and amenorrhoea (the absence of menstruation during reproductive years). 

Some studies have indicated that there is a link between HIV infection and premature ovarian failure. Population dynamics also play a role in decreased fertility in HIV-infected women, because in places where clinical resources are limited, the prevalence of premature mortality is higher. 

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An April 2017 article published in the journal AIDS said that in HIV-positive women, longer duration of infection is linked with greater relative fertility reduction. High viral load is associated with reduced pregnancy rates and reduced live births. 

HIV-positive women are at an increased risk of preterm birth, intrauterine growth restriction, stillbirth, and preeclampsia. 

Without intervention, an HIV-infected woman has a 13 to 30 per cent risk of infecting her baby. This is called vertical transmission, and can occur during pregnancy, delivery or breastfeeding. 

HIV-infected patients are more likely to suffer from sexually transmitted diseases like syphilis, which in turn leads to biological alterations, impacting fertility. 

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How HIV impacts fertility in men

In HIV-infected men, semen volume, concentration, sperm motility, and morphology are affected, resulting in reduced fertility. HIV-infected men are also more likely to have orchitis, an inflammation of one or both testicles; hypogonadism, a condition in which the testes produce little to no hormones; and leukocytospermia, a condition characterised by a high concentration of white blood cells in semen. The World Health Organization (WHO) seconds leukocytospermia as a condition in which one millilitre of semen has more than one million white blood cells. 

Highly active antiretroviral therapy can also result in sperm morphological and topographical changes. Recent studies have shown that this therapy decreases total sperm count and motility, and increases the proportion of abnormal sperm forms. 

“HIV-positive males may face reduced fertility due to the virus affecting sperm quality and quantity. HIV can impact the testicles, leading to lower semen volume and altered sperm morphology. Additionally, inflammation in the genital tract may contribute to fertility issues. However, the extent varies, and not all HIV-positive males experience infertility. Timely antiretroviral therapy can mitigate these effects, emphasising the importance of managing the virus to support reproductive health. Regular monitoring and medical guidance can help navigate potential fertility challenges in HIV-positive individuals,” Dr Aruna Kalra, Senior Gynecologist & Obstetrician at CK Birla Hospital, Gurugram, told ABP Live.

About 60 per cent of men with advanced HIV have erectile and ejaculatory dysfunction. Testosterone levels decrease in HIV-infected men as the disease progresses. 

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How HIV-positive individuals can give birth to children free of HIV

HIV has a cytopathic effect, or changes the structure of host cells, and results in chronic inflammation, fever, malnutrition, and infections of reproductive organs. Since inflammation can impact reproductive organs, immune health is of utmost importance in HIV-positive individuals. They must undergo proper treatment to maintain a robust immune system, and remain fertile.

“HIV/AIDS can affect fertility by compromising immune function and causing reproductive issues. While it doesn’t inherently make individuals infertile, it can lead to conditions hindering conception. Current research suggests antiretroviral therapy improves fertility outcomes for HIV-positive individuals. Future implications involve ongoing advancements in treatment and reproductive technologies. Immune health is crucial. This is because HIV-associated inflammation may impact reproductive organs. Maintaining a robust immune system through treatment and overall health is vital for fertility in HIV-positive individuals,” said Dr Kalra.

HIV infection can also result in oligospermia, which refers to a low sperm count (15 million sperm in one millilitre of semen). In order to reduce the impact of AIDS on fertility, other sexually transmitted infections must be prevented.

“In HIV-positive individuals, there are multiple factors which can affect fertility. Cytopathic effect of HIV, chronic inflammation, fever, malnutrition, opportunistic infections of testes and malignancy of testes can be contributing factors for the same. It may result in oligospermia, low volume of semen and an increase in abnormal sperm. Immune health is an important factor and is an essential part of sexual health. Prevention of other sexually transmitted diseases would also play a major role in reducing the impact on fertility,” Dr Prakash Bora, M.D, D.V.D, Hon-Dermatologist, Godrej Memorial Hospital, Mumbai, told ABP Live.

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The risk of transmission of HIV in a serodiscordant couple, where one of the partners is HIV-positive and the other is HIV-negative, can be reduced with the help of antiretroviral therapy. The transmission rates can be reduced to less than two per cent with the help of effective antiretroviral therapy during pregnancy and childbirth. Antiretroviral drugs can reduce transmission risk during breastfeeding. 

Combination antiretroviral therapy has shown significant improvements in life expectancy and quality of life for both children and adults infected with HIV in developed countries. Earlier, AIDS was associated with certain death but with antiretroviral therapy, the life expectancy has become 20 years from the time of diagnosis. If combination antiretroviral therapy is judiciously used during pregnancy and labour, and delivery is performed by caesarean section, the risk of vertical transmission is reduced to less than two per cent, according to a March 2001 article published in the British Medical Journal. 

However, antiretroviral drugs taken during pregnancy often show teratogenic effects, or disturb the growth and development of an embryo or foetus.

“With proper medical care, the risk of HIV transmission from an HIV-positive parent to a child is significantly reduced. Effective antiretroviral therapy during pregnancy and childbirth, along with preventive measures, can lower transmission rates to less than 2%. Maternal outcomes often improve with treatment, enhancing overall health. Infant outcomes depend on timely interventions; antiretroviral drugs can minimise transmission risk during breastfeeding. Regular medical monitoring and adherence to protocols contribute to healthier outcomes for both mother and child in HIV-affected pregnancies,” said Dr Kalra.

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Assisted reproductive technology (ART) is a boon for HIV-positive individuals. HIV concordant couples, in which both the partners are HIV-positive, should choose ART if they wish to reproduce. In the case of unprotected intercourse, the risk of transmission of HIV from a HIV-positive man to the female partner is 0.1 to 0.2 per cent. Therefore, such a woman attempting to conceive naturally has a serious risk of contracting HIV, and also carries a risk to the child. 

In the case of HIV-infected men, the virus is present in the semen as free virus in the seminal plasma, and as cell-associated virus in the non-sperm cells. 

Therefore, to reduce the risk of viral transmission, spermatozoa should be first washed free of seminal plasma and non-sperm cells before insemination into the woman at the time of ovulation. This is called sperm washing. 

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After sperm washing, intrauterine insemination can be performed, or in-vitro fertilisation can be conducted, in HIV serodiscordant couples. 

The woman should also consume pre-exposure prophylaxis (PrEP), a drug for people at high risk of HIV through sexual intercourse or drug use. 

According to an article published by Penn Medicine, PrEP is safer and cheaper than in-vitro fertilisation or intrauterine insemination, and is 99 per cent effective at preventing HIV infection when the person adheres to the medication. 

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According to the Centers for Disease Control and Prevention (CDC), the risk for transmission from an HIV-infected man to an HIV-negative woman is low if appropriate risk reduction strategies such as the use of highly active antiretroviral drugs, antiretroviral pre-exposure prophylaxis and sperm washing, are implemented. 

Also, sperm washing in men who are taking HIV medicines before intrauterine insemination or in-vitro fertilisation helps reduce the risk of HIV infection even more.

“Parent to child transmission can be prevented by appropriate precautions & measures.  Treatment of primary infection in parents and ensuring that their viral load of HIV is undetectable with appropriate assisted reproductive technology (ART) is the mainstay. High viral load is the most significant cause of high risk of transmission to the child. Care of the mother during pregnancy along with ART is important. Infant is given prophylactic ART. All these measures can reduce the risk of transmission to 1-2%,” said Dr Bora.

HIV-infected men may become infertile several years after diagnosis, but the probability is low. Mostly, the effect of antiretroviral therapy, and the biological impacts of the virus on gonads can lead to infertility in men.

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