The case for routine HIV screening before IVF treatment

A survey of UK IVF centre policies

Samuel F. Marcus1,3, Susan M. Avery1, Naim Abusheikha1, Nisrin K. Marcus2 and Peter R. Brinsden1

1 Bourn Hall Clinic, Bourn, Cambridge, CB3 7TR, and 2 The Surgery, 281 Mill Road, Cambridge CB1 3DG UK


    Abstract
 Top
 Abstract
 Introduction
 Questionnaire to all licensed...
 Responses obtained
 Varying policies in the...
 References
 
The case for routine human immunodeficiency virus (HIV) screening of all couples seeking assisted reproductive treatment is so strong that it should be made obligatory for all couples entering IVF programmes to be given information about HIV transmission, and offered testing. In August 1999, questionnaires regarding routine HIV screening of couples seeking IVF treatment were sent to the medical directors of the 74 licensed assisted conception units in the UK. Of the 45 (60.8%) centres who responded, 19 (42.2%) routinely screen both partners for HIV antibodies, 25 (55.5%) do not screen and one centre selectively screens high-risk patients. There was no significant difference in the proportion of centres that routinely carried out screening with regards to the unit size: six out of 13 (46.2%) small units compared with 13/32 (40.6%) large units. In all, 17 centres (37.8%) rated HIV screening as essential, nine (20%) as desirable, 11 (24.4%) as not required, while eight (17.8%) centres did not comment. Of the 19 centres that have a routine screening policy, 18 have management protocols in the event that the test is positive. Of these 18 centres, 12 adhere rigidly to the protocol, while five centres adhere to the protocol with few exceptions and the remaining one uses its protocol for guidance only. The main reasons for not employing routine HIV screening were: the lack of cost effectiveness, low prevalence of HIV infection in their population, necessity for and cost of counselling, uncertainty about the need for screening and potential delay to start of treatment.

Key words: UK survey/HIV screening/IVF


    Introduction
 Top
 Abstract
 Introduction
 Questionnaire to all licensed...
 Responses obtained
 Varying policies in the...
 References
 
The future welfare of any child born as a result of assisted conception treatment should be carefully considered before commencing treatment. By the end of April 1999, there were 1470 babies born to mothers infected with human immunodeficiency virus (HIV) in the UK (AIDS and HIV infection in the UK, 1999aGo). The risk of vertical transmission of HIV from mother to child has been variously reported, and ranges from 15–20% in the European and American population to 25–45% in Africa, India and Thailand (Peckham and Gibbs, 1995Go; Newell et al., 1997Go).

Measures to prevent vertical transmission of HIV from mother to child can only be effective if HIV infection is diagnosed before or during pregnancy. It is known that >70% of HIV-infected women remain undiagnosed at the time of delivery (Nicoll et al., 1998Go; AIDS and HIV infection in the United Kingdom, 1999bGo). Many women do not become aware of their own infection until their child becomes symptomatic of HIV infection or is diagnosed with acquired immune deficiency syndrome (AIDS) (Unlinked Anonymous Surveys Steering Group, 1997Go).

In this study, we present the results of a questionnaire, which was sent to all licensed IVF centres in the UK in August 1999, enquiring about their policy of routine HIV screening of couples seeking IVF treatment. In addition, we compared the results of our survey with a similar survey carried out 4 years previously (Balet et al., 1998Go) in order to determine whether there had been any changes in the attitude of UK centres toward routine HIV screening.


    Questionnaire to all licensed IVF centres
 Top
 Abstract
 Introduction
 Questionnaire to all licensed...
 Responses obtained
 Varying policies in the...
 References
 
A postal questionnaire was sent to the Medical Directors of all licensed IVF centres in the UK in August 1999. The questions were: (i) do you routinely screen both partners for HIV prior to IVF treatment?; (ii) how do you rate the importance of such screening? (essential/desirable/not required/do not know); (iii) do you have a management protocol in place should a test prove positive?; (iv) how rigidly do you adhere to your management protocols? (rigidly/mostly adhered to with few exceptions/use it only for guidance); (v) if you do not have a current policy of routine screening what are your views about implementing such a policy?; (vi) what is the size of your unit as classified by the HFEA, i.e. small (<200 treatment cycles per year), or large (>=200 cycles per year); and (vii) any comments?


    Responses obtained
 Top
 Abstract
 Introduction
 Questionnaire to all licensed...
 Responses obtained
 Varying policies in the...
 References
 
Questionnaires were sent to all 74 licensed IVF units in the UK and 45 (60.8%) responded: 13 could be classified as small (<200 treatment cycles per year), and 32 as large units, as defined by the HFEA. Of these, 19 (42.2%) centres performed routine HIV screening for both partners, while 25 (56.8%) centres did not perform routine screening and one centre offers selective screening for high-risk patients (Table IGo). The size of the unit did not influence the decision to carry out routine screening, six out of 13 (46.2%) of the small units compared with 13/32 (40.6%) in large units (Table IGo).


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Table I. Human immunodeficiency virus (HIV) screening policy in the IVF centres in the UK, which replied to the questionnaires (n = 45)
 
Of the 45 centres which responded to the questionnaire, 17 (37.8%) rated HIV screening as an essential test, nine (20.0%) as desirable and 11 (24.4%) as not required; the remainder did not know (Table IIGo).


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Table II. Rating by the centres of the importance of routine human immunodeficiency virus (HIV) screening
 
Of the 19 centres that carry out routine HIV screening, 18 had a protocol of management in place should the result of HIV testing be positive. One centre did not have such a protocol (Table IIIGo).


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Table III. Number of IVF centres carrying out routine human immunodeficiency virus (HIV) screening, grouped according to whether a management protocol for cases with a positive test is in place
 
Of the 18 IVF centres which had a management protocol, 12 centres stated that they adhered rigidly to it, five mostly adhered it (with a few exceptions), and one centre used its protocol for guidance only (Table IVGo).


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Table IV. The degree of adherence to the management protocols for human immunodeficiency virus (HIV) positive patients by centres which have management protocols in place
 
Table VGo summarizes the views of the 25 centres which do not currently have a policy of routine HIV screening regarding the implications of introducing such a policy. The most common factor was the cost implication, followed by perceived low-risk, counselling implications, uncertainty about the need for screening and a possible delay in starting treatment. Two centres viewed the concept of introducing such a programme positively.


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Table V. Implications of introducing a screening policy, as perceived by IVF centres which do not routinely screen for human immunodeficiency virus (HIV) in couples seeking IVF treatment into their programmes. Some centres expressed more than one view
 

    Varying policies in the UK
 Top
 Abstract
 Introduction
 Questionnaire to all licensed...
 Responses obtained
 Varying policies in the...
 References
 
On the evidence of the responses to the questionnaires, routine HIV screening policies vary widely between IVF centres in the UK. Less than half of the IVF centres that responded to the questionnaires routinely screen all couples seeking IVF treatment. Nineteen centres were uncertain of the need for routine screening, despite the increase in the rate of HIV infection in the UK among women of childbearing age. No significant shift in the attitude of UK centres toward routine HIV screening was noted since a previous survey 4 years ago (Balet et al., 1998Go). They reported that only 23 (39.7%) of the 58 centres that responded to their questionnaire in 1995 performed HIV testing. Is it now the time for all IVF centres to adopt a policy of routine HIV screening, or at least offer and recommend the screening of couples seeking treatment?

The UK Department of Health has recently recommended that all health authorities should implement a policy of offering and recommending HIV testing to all pregnant women along with other antenatal screening tests as an integral part of their antenatal care. The aim of the policy is to identify 80% of HIV infected women antenatally by 2002, with the hope of an 80% reduction in the number of children born with HIV infection (Department of Health, 1999Go).

The welfare of the child clause in the Human Fertilisation and Embryology Act 1990 (HFEA, 1991) states that, the welfare of the child should be carefully considered before undertaking assisted reproduction treatment. The American Society for Reproductive Medicine (ASRM, 1993), issued guidelines against the provision of assisted conception treatment to HIV-infected individuals or couples. The International Federation of Gynecology and Obstetrics (FIGO) Committee for the Study of Ethical Aspects of Human Reproduction guidelines states that to protect the interest of those at risk of unwanted exposure to HIV, including the potential child, only seronegative individuals should be allowed to participate in treatment (Schenker, 1997Go). The guidelines of the European Society of Human Reproduction and Embryology (ESHRE) state that after counselling screening for HIV antibodies should be included in a fertility clinic protocol (ESHRE, 1995). Given that not all IVF centres in the UK currently offer routine HIV screening, and that the majority of HIV patients in the UK are unrecognized, it is inevitable that some unrecognized HIV women or their partners will be offered fertility treatment. If this happens, the clinician may share the responsibility for the birth of a HIV-infected infant. There is also the possibility of premature death of one or both parents from HIV-related pathology and the child being orphaned. Without any treatment, HIV infection in children results in chronic disease and ~20% of HIV-infected children develop AIDS or die in the first year of life (Blanche et al., 1997Go). The lifetime cost of care for a child infected with HIV has been estimated at £178 300 (Postma et al., 1999Go).

Routine screening of the couple is not only important for the welfare of the unborn child but also for the benefit of the parents. The British HIV Association (BHIVA) advocates the use of antiretroviral therapy as the best prospect for prolonged health in pregnant women as well as reducing vertical transmission rates (BHIVA Guidelines Co-ordinating Committee, 1997Go).

In addition, consideration should be given of the possible risk (however slight), to the health care staff involved in the care of such patients (Gerberding, 1994Go; Duff et al., 1999Go), as well as to the risk of cross-contamination to other gametes and embryos in incubators or freezers (Categorization of Biological Agents, 1995Go; Case-control Study of HIV Seroconversion in Healthcare Workers, 1995Go; Occupational Acquisition of HIV Infection among Health-Care Workers in the UK, 1997).

In 1987, Bourn Hall Clinic introduced a policy of testing all new and existing patients undergoing assisted conception treatment for HIV and hepatitis B virus (HBV). Testing for hepatitis C virus was also introduced in 1996. During this period 4960 patients consented to be tested for HIV. Three patients (0.06%) were confirmed to be positive for HIV. These patients were not aware of their seropositivity status and none had symptoms or signs suggestive of infection (Abusheikha et al., 1999Go).

If all IVF units were to adopt a similar screening policy, infected individuals would be identified. Should they decide to proceed with treatment, they should then do so in specialist units with a multidisciplinary approach. These units would also require laboratory facilities equipped to handle high-risk samples. There is clear evidence that vertical transmission can be greatly reduced from 25 to <5% by interventions such as antiretroviral drugs, delivery by Caesarean section, careful obstetric management and bottle-feeding (Dunn et al., 1992Go: Connor et al., 1994Go; Peckham and Gibbs, 1995Go; Blanche et al., 1997Go; Duong et al., 1999Go; European Collaborative Study, 1999Go).

All patients undergoing testing for HIV should have the opportunity for pre-test discussion/counselling in order to minimize the psychological abreaction arising partly from society's attitude to the disease and partly from the absence of curative treatment (Department of Health Guidelines for pre-test discussion on HIV, 1996). Information given to couples should include the route by which HIV infection is acquired and the risk of vertical transmission. Couples should understand that having an HIV infection is different from having AIDS and that there are treatments to reduce the rate of progression of the disease. The patient should be made aware of the implications of having a positive result, including the effects on the relationship with their partner and other family members, employment and life insurance (Temmerman et al., 1995Go; Miller and Madge, 1997Go).

All centres carrying out screening should have a management policy to enable them to respond to positive test results. Our survey showed that 95% of the centres had policies in place but only two-thirds of them adhere rigidly to their protocols.

Fertility treatment of HIV infected women or of their HIV-infected male partners is a contentious issue. There are many ethical and legal issues surrounding the IVF centres' obligation to provide care for HIV patients (Doyle and Delany, 1991Go; Smith et al., 1991Go; Rojansky and Schenker, 1995Go; Anderson, 1999Go). Undoubtedly, some couples may decline to undergo fertility treatment if they know that they are infected with HIV. For example, six women in one series (Olaitan et al., 1996Go) declined further infertility investigations or treatment after discovering their HIV status.

Currently, the majority of IVF centres in the UK do not provide fertility treatment to couples if either partner is HIV infected, mainly because of consideration for the welfare of the unborn child. There is currently no legal obligation to treat HIV-positive patients. For some centres, a negative HIV result is a condition of acceptance for treatment, while others accept and treat HIV-positive patients.

Balet et al. reported that out of the 58 centres that responded to their survey, nine had already provided treatment for couples in whom the male partner was HIV positive and two centres to HIV-positive women (Balet et al., 1998Go). Another group of authors (Bongain et al., 1994Go) reported that most gynaecologists in France refused to treat infertile HIV positive patients. Most fertility clinics in the USA screen patients for HIV and deny assisted reproduction treatment to individuals found to be positive (Anderson, 1999Go).

It is essential that all centres, regardless of whether or not they accept the treatment of HIV-positive patients, should offer these patients sympathetic support, counselling and information. These must be given promptly together with early referral to local HIV care services.

The question arises as to whether doctors have the right to refuse infertility treatment to a well-informed couple where one of the partners is HIV seropositive. The conflict here arises between the doctor's moral obligation to treat the couple and his or her responsibility toward the welfare of the potential child. The right to be treated is questionable in cases of seropositive women where the viral process is in an advanced stage and the risk of vertical transmission to the child cannot be substantially reduced. The necessary antiretroviral drugs would have to be suspended during the first 3 months of pregnancy, owing to possible teratogenic effects (Olaitan et al., 1996Go).

Most of the HIV virus found in semen, is present in the seminal plasma and white cells, and careful sperm washing procedures can reduce the number of HIV particles by >10 000 times (Quayle et al., 1998Go). Seropositive men do not need to suspend their antiretroviral drugs, which suppress HIV in semen although they do not eliminate the virus completely (Zhang et al., 1998Go). After extensive counselling it seems acceptable to treat a couple where the male partner is HIV positive. Semprini (1997) carried out >1000 artificial insemination cycles with washed semen in serodiscordant couples (seropositive male and seronegative woman) (Semprini, 1997Go). Of 250 babies born, not one, nor the inseminated women, have been infected. One group (Marina et al., 1998aGo) reported that they carried out 101 artificial insemination cycles in 63 seronegative women with washed semen from HIV-positive men, and that in 37 babies, no seroconversion of the inseminated women has taken place and all the children were born seronegative. Subsequently, the same group (Marina et al., 1998bGo) reported the first pregnancy achieved in a seronegative woman following IVF/intracytoplasmic sperm injection (ICSI) from an HIV-infected man.

All prospective gamete donors in the UK are required to have an HIV test conducted in clinics licensed and inspected by the HFEA. The question then arises, should the HFEA make a policy of routine HIV screening of all couples seeking IVF treatment and issue guidelines for management of HIV-positive patients? This would remove the responsibility of making such difficult and ethical judgements from the clinicians; there would be uniformity across all IVF centres, clarity for patients and protection for staff and other patients.

Undoubtedly, implementation of routine HIV screening has some resource implications. On the evidence provided by this study, most IVF centres do not have a policy for routine HIV screening because they do not consider screening to be cost-effective in terms of the low prevalence rate in their target population, and/or because they cannot see the need for expensive counselling, because of uncertainty about the need for the screening and the potential delay to the start of treatment. We believe that a policy of routine screening of all patients seeking infertility treatment is justifiable. The cost of HIV testing is only a fraction of the overall cost of an IVF treatment cycle. Good clinical practice justifies the extra manpower costs.

Some argue that screening is not required because of the low prevalence of HIV infection in their population. There is a considerable geographical variation in the prevalence of HIV in pregnant women, with the highest prevalence in London, where 1 in 500 births (and in some London districts 1 in 200 births), were to HIV infected mothers. Outside London, the prevalence is about 1 in 6000 (Nicoll et al., 1998Go).

The prevalence of HIV among couples seeking IVF treatment is unknown. Edelstein et al. (1990) reported a prevalence of 0.059% in patients and their spouses entering a large IVF programme. Abusheikha et al. (1999) reported a prevalence of 0.06% in their series of 4960 patients. Although both studies revealed a low prevalence rate, these could be underestimates. In the absence of a universal screening policy among IVF centres, patients who are known to be HIV positive or who fear they are infected may be inclined to seek treatment in centres where there is no screening, thus continuing to conceal their HIV-positive status during a possible pregnancy and being excluded from active management to decrease the risk of vertical transmission to their child.

Some IVF centres advocate selective screening of `high-risk groups' only. The argument against this policy arises from the fact that many HIV-infected patients fall outside these groups (Edelstein et al., 1990Go; Abusheikha et al., 1999Go; Foley and Harindra, 1999Go). A discussion on selective versus universal antenatal HIV testing (Ades et al., 1999Go) concluded that overall prevalence does not form an adequate base for determining screening strategy. Instead, universal screening can be justified either because the prevalence of HIV in the low-risk group is sufficiently high or because it achieves sufficiently higher uptake relative to selective screening among those at higher risk. We can assume that the same can be applied in assisted conception programmes. In addition, routine testing causes less anxiety to the couple compared to selective screening, as it eliminates the stigma of saying, `yes' to the testing. This was emphasized by an analysis of the opinions of pregnant women about HIV testing (Boyd et al., 1999Go), while another group (Patrick et al., 1998Go) assessed the cost effectiveness of HIV screening in a low-prevalence population and concluded that screening may be comparable with other widely-accepted health care expenditure, in terms of cost-effectiveness.

In conclusion, the future welfare of any child born as a result of assisted reproduction treatment should be carefully considered before starting treatment. The case for routine HIV screening of all couples seeking assisted reproductive treatment is now so strong that it should be made obligatory for all couples entering IVF programmes to be given information about HIV transmission and offered testing. We welcome the Department of Health recommendation that antenatal testing for HIV should be offered to all pregnant women. Perhaps it would be appropriate if the HFEA laid down similar recommendations. Despite the low seropositivity rate, we believe that viral screening is justified, since we are dealing with life-threatening diseases. Refusing to offer infertile couples HIV testing deprives them of the chance of making informed decisions and giving consent with regard to treatment, and denies them the opportunity of taking the measures that could not only lessen the chance of HIV transmission from mother to baby but also slow the progression of their own disease.

Requests from HIV positive patients for fertility treatment raise medical, ethical and legal problems for the healthcare provider. The welfare of the potential child, protection of the uninfected gametes in the laboratory and of health care workers from exposure to HIV, the provision of adequate medical care and counselling to HIV positive couples, and the maintenance of patient confidentiality are all of prime importance. It is against these factors that we must weigh the issue of discrimination.


    Acknowledgments
 
The authors wish to thank all the IVF centres that responded to our questionnaire. We also wish to extend our thanks to The National Study of HIV in Pregnancy.


    Notes
 
3 To whom correspondence should be addressed at: Bourn Hall Clinic, Bourn, Cambridge CB3 7TR, UK. E-mail: sf.marcus{at}virgin.net Back

This debate was previously published on Webtrack, June 1, 2000


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 Introduction
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 Responses obtained
 Varying policies in the...
 References
 
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