Risque viral et procréation Comment diminuer le risque de transmission pour les couples séro-différents (VIH et/ou VHC)? Pr Ch. PASQUIER Laboratoire de Virologie, CHU Toulouse, France JNI 8/06/2005
Evidence for HIV-1 in semen Epidemiological evidence Sexual transmission Transmission using donor semen (MMWR 1990) Virological evidence : HIV can be detected in semen by Culture P24 antigen detection RNA and DNA detection
HIV risk and natural procreation Risk of transmission during a single sexual intercourse is low Estimated at 0.05 to 0.15 % per act This risk is not acceptable and unprotected intercourse must not be recommended The systematic condom use induced an Artificial sterility
Procreation without HIV risk (HIV infected man) No risk Child adoption Insemination with donor sperm Decreased risk Unprotected intercourse on the day of ovulation (Mandelbrot et al, Lancet 1997) Medically assisted procreation
MAP technologies Inséminations intra-utérines Dysovulation Glaire cervicale anormale Anomalies modérées du sperme Fécondation In Vitro ICSI Pathologie tubaire Anomalies sévères du sperme Echec des inséminations Couples hypofertiles Pr. Parinaud
Location of HIV in semen 90% plasma 10% cells HIV DNA ± RNA HIV RNA No evidence in favour of HIV infection of spermatozoa
Risk reduction using MAP Use of sperm processing (sperm-wash) Discard seminal plasma Discard round cells (lymphocytes, ) Isolation of motile spermatozoa Use of MAP Reduce the number of potential exposition to HIV by monitoring, ovulation induction, Choice of MAP technique (2x10 6 or less spermatozoa)
Spermatozoa Processing Density gradient + swim-up Semen Step 1 Step 2 Step 3 plasma round cells spermatozoa 50 % 70 % 90% Swim-up centrifugation
Detection of HIV genome HIV genome in semen 171/832 21% HIV RNA in seminal plasma 114/832 14% HIV DNA in semen cells 45/793 6% HIV RNA in semen cells 66/764 9% HIV genome after preparation 0/804 0% Pasquier, AIDS 2000, Bujan AIDS 2004
Detection of HCV genome in semen fractions HCV genome in semen 45/389 12% HCV RNA in seminal plasma 45/389 12% HCV RNA in semen cells 0/134 0% HCV genome after preparation 0/115 0% Pasquier J Med Virol 2004
Can we predict HIV shedding in semen? or Is HIV detection in semen systematically needed?
HIV-1 viral load seminal plasma vs blood Seminal plasma frequency 120 100 80 60 40 20 (-) (-) P <0.01 (+) 7.9% (+) Non-detectable in semen (n=233) Detectable in semen (n=38) 19.4% 0 Non-detectable Detectable Blood Plasma Detection with non-detectable blood viral load occurred in 7.9% Bujan et al, AIDS 2004
Intermitent HIV-1 shedding Log copies / ml 6 5 4 3 2 CD4 cells 3.8 3.2 2.2 3.0 Case report + - + - + + - - - 2.9 5.4 2.7 4.2 2.5 2.8 2.7 2.8 05 11 03 12 05 09 02 03 05 1998 1999 2000 2001 Seminal cells 715 692 577 545 474 612 573 541 / µl blood 2.1 semen Polynuclear cells 0 0 0 0 4.2 6.3 0 0 x10 6 /ejaculate Bujan et al, Fertil Steril 2002
HIV shedding in semen Associated with : Low CD4 Cells count AIDS clinical stage No HIV treatment or non-optimal treatment Leucocytes in semen There is no predictive marker valid for HIV shedding in one individual man
Other HIV risk in AMP Risk of nosocomial infections not directly linked to MAP techniques Risk of unprotected sexual intercourse
Toulouse PMA results of IUI program 84 couples, 298 IUI cycles 56 pregnancies : 18.8% /cycle 44 deliveries, 52 children 9 miscarriages : 16.07% /pregnancy 3 ongoing pregnancies Update 2005 159 couples 402 cycles 76 pregnancies 64 children couples with pregnancy : 57 % take home baby rate : 52.4% NO HIV contamination of women Bujan, Fertil Steril 2004
Conclusion (1) Sperm processing techniques are effective to obtain spermatozoa without HIV detection Semen must be systematically tested for HIV because of Unpredictable intermittent shedding Risk of processing errors Development of quality control should help to find optimal algorithm for HIV risk reduction Results of the first QC are under analysis
Conclusion (2) In France legal limits apply to MAP (decree - Arrêté du 10 mai 2001) CD4 cells counts > 200 µl, stable for 4 months HIV-1 Viral load in blood stable for 4 months Viral load in seminal plasma is required to choose MAP technique < 1,000 c/ml 1,000 to 10,000 c/ml > 10,000 c/ml all MAP techniques ICSI or IVF only no MAP possible Final sperm fraction is systematically tested for HIV Couple evaluation by a multidisciplinary team
AMP à risque viral HIV en France Bruxelles Rennes Bichat Pitié Cochin Strasbourg Lausanne Toulouse Lyon Marseille Milan Barcelonne
Acknowledgments Laboratory of Virology CHU Toulouse L. Righi, S. Ginesta, L. Berges, A. Harter, M. Cartery, C. Souyris, J. Izopet Laboratory of Spermiology CHU Toulouse L. Bujan, M. Daudin Involved Physicians P. Massip, A. Berrebi Funding and support French AIDS agency (ANRS), ARS, CREAThE