The American Journal of Bioethics

Approximately one million Americans are infected with human immunodeficiency virus type 1 (HIV-1). Most of them are young heterosexual adults of reproductive age. Many desire to have children. Highly active antiretroviral therapy (HAART) has dramatically altered the clinical course of this disease. As a result of HAART the general health and life expectancy of HIV-1 seropositive men is much improved. Assisted reproductive techniques that separate motile sperm from seminal plasma and nonmotile cells known to harbor virus has been offered as a means of reducing viral transmission to the uninfected female desiring to become pregnant. Although this treatment has been available in Europe for more than a decade, very few centers in the United States provide HIV-1 serodiscordant couples options for reproductive care. In light of mounting evidence of the safety of treatment, and fueled by an increasing demand for reproductive services by HIV-1 serodiscordant couples, the Center for Women's Reproductive Care at Columbia University established a program for addressing their needs. Major ethical principles related to autonomy, nonmaleficence, beneficence, and justice were individually considered in deciding to proceed with treatment.

Background and Introduction

More than 30 million people are infected with human immunodeficiency virus type 1 (HIV-1) (Centers for Disease Control 2000). The virus is viewed as a modern plague, presenting a formidable challenge to society and medicine. Although the epidemic threatens to kill millions throughout the impoverished world, in more affluent countries the introduction and availability of antiviral drugs has radically changed the prognosis of infected young adults. A better understanding of the biology of the virus and its mode of transmission has led to remarkable therapeutic advances and altered the clinical course of illness. Acquired immune defi- ciency syndrome (AIDS) remains a serious disease; if not treated, patients typically succumb to either opportunistic infection or cancer. However, with appropriate medical intervention the disease usually evolves toward chronicity and patients generally enjoy years of good health. Today many American patients living with HIV-1 infection are doing well and are fully integrated into society. These individuals are actively making plans for a future, which logically includes establishing long-term relationships and beginning a family. Responsible men and women living with HIV-1 are seeking help from physicians in order to accomplish these goals without placing their uninfected partners at risk. Unfortunately, in most cases they are discouraged from proceeding or simply denied access to reproductive care.

Despite advances in the treatment modalities and the delivery of healthcare to HIV-1-infected patients, debate continues as to whether physicians should provide assisted reproduction to couples in whom the male partner is known to be HIV-1 seropositive (Englert et al. 2001; Anderson 1999). Specifically, there are grave concerns regarding the potential risk of transmitting virus to the embryo, fetus, or mother, as well as worries over the socioeconomic impact of raising a child by a parent with a potentially fatal disease. HIV-1 infection occurs primarily in young, reproductively fit, and sexually active men. However, safe sexual practice includes the use of condoms and precludes any hope of pregnancy. The implementation of sperm-preparation techniques, popularly referred to as "sperm washing," appears to reduce the probability of horizontal transmission and has been recommended for nearly ten years as a means for HIV-1 serodiscordant couples to have a child (Semprini et al. 1992). Yet most practitioners in the United States are unwilling to offer therapy for fear of infecting the seronegative partner and child. In the early 1990's several professional societies, including the Centers [End Page 33] for Disease Control (CDC) published recommendations against treating HIV-1 serodiscordant couples (CDC 1990; American Society for Reproductive Medicine 1993). Prohibitions were then based largely upon information available prior to 1990, a time in which HIV-1 was typically considered to be highly infectious and fatal if...