Student Capstone Research Cited in CDC Revised Guidelines

When Maryam Zafer’s capstone project for her master’s degree in Global Health Sciences didn’t work out in the spring of 2014, she jumped at the first project she was offered: a systematic review of the research on semen washing, a strategy for preventing HIV among couples who want to conceive a child when the man is HIV positive.

Today she’s a published researcher whose work provided the evidence the Centers for Disease Control used to revise its guidelines regarding semen washing.

“I was thrown into this and I was very lucky,” she says.

Joelle Brown, PhD, her mentor for the project, thinks she’s the lucky one. “Maryam stepped right in, worked very well with our international team, and did not require a lot of supervision,” Brown said.  At the time Brown, associate professor of Epidemiology and Biostatistics at UCSF, was a member of a World Health Organization committee developing evidence-based guidelines for HIV prevention strategies for discordant couples, those who want to have a baby and one partner is HIV positive.

“The desire for biological children is common among HIV-infected individuals. HIV-discordant couples—those where one partner is HIV positive—face a difficult choice between attempting pregnancy and risking HIV transmission to their partners,” Brown said.  “Strategies for safer methods of attempting pregnancy, including semen washing, viral suppression in the HIV-positive partner, and pre-exposure prophylaxis (“PrEP”) in the HIV-negative partner, are urgently needed to decrease the risk of HIV transmission between HIV-discordant partners as they exercise their right to build a family.”

Semen washing is a technique available since the late 1980s that isolates the sperm from other parts of the seminal fluid, where HIV exists so that the receiving partner does not get infected.

In 1988, the CDC recommended against semen washing in the US, though the technique has been used quite a bit in Europe over the past 25 years, according to Brown.

Zafer and Brown’s research, a systematic review and meta analysis of previous smaller studies on the effectiveness of semen washing in preventing HIV transmission, found that there were no instances of HIV transmission among 4000 couples who used the technique for more than 11,500 inseminations.

Importantly, about half of the men in these studies were not taking antiretroviral therapy (ART) and were not virally suppressed at the time of semen washing, suggesting that semen washing is a safe and effective prevention method in settings where men are unable or unwilling to initiate antiretroviral therapy, are nonadherent or are not virally suppressed. Over half of couples included in the systematic review achieved pregnancy. Their research was published in the journal Fertility and Sterility in March 2016.

“The benefit of systematic review is that it is able to provide more data points than an individual study, which affords more statistical power and more confidence in the results and conclusions,” said Zafer, now a medical student at Icahn School of Medicine at Mt. Sinai in New Your City.  She worked with Brown to review 243 research papers, isolate those with valuable data, compile the data and write up the results of their findings.

“Our research shows that semen washing is a safe option for couples who want to get pregnant,” she said.

On June 2, the CDC released new information in which they agreed and reversed their previous recommendation against semen washing for HIV positive men.  “This is a welcome reversal, as it may lead to HIV discordant couples having more prevention strategies to choose from when they want to conceive,” Brown said.  “Offering semen washing as an option may be particularly important in countries most affected by HIV, where ART coverage is not universal, where individuals may not be virally suppressed, and where PreP is not widely available or affordable. This technique can give couples hope,” she said.

In the end, discordant couples may be the truly lucky ones.