Assisted reproduction and HIV: Separate but not equal

Federal law stipulates that separate laboratory facilities and storage tanks, so-called “double set-ups,” are required for handling reproductive tissue from people living with HIV (PLHIV). The American Society for Reproductive Medicine (ASRM) asserts the medical, legal, and ethical obligations to provide equal access to assisted reproductive care for PLHIV, with the stipulation that those without sufficient resources should refer patients appropriately. Meanwhile, the ASRM reports that fewer than 3% of U.S. fertility practices openly provide care to this population, suggesting major disparities. Complicating the picture, survey data suggest that as many as 50% may be willing to provide care. To explore this issue, we systematically map and then analyze the medical, legal, and ethical contexts for providing assisted reproduction to U.S. PLHIV. We find that: (1) Assisted reproduction for PLHIV has over 30 years of demonstrated safety and efficacy, mostly in Europe and Canada; (2) Federal antidiscrimination laws and CDC guidelines provide the legal basis for equal access to reproductive healthcare, and legally mandated “universal precautions” prevent the spread of communicable disease in healthcare settings; and, (3) Over 50 publications spanning 25 years document the ethical arguments, invoking beneficence, justice, autonomy, and reproductive rights, in favor of assisted reproduction for PLHIV. Our analysis concludes that the “double set-up” requirement and the “treat or refer” imperative may contribute to ongoing disparities. The “double set-up” policy may not be medically necessary, but makes it cost-prohibitive for most fertility clinics to provide assisted reproductive treatment to PLHIV. Furthermore, meaningful referral is hindered by a lack of transparency regarding availability of services. We conclude with a proposal for critical reevaluation of national policy and practices.