Twenty years ago, when Meg Sullivan started as an infectious disease specialist at Boston Medical Center, working with HIV-positive women, the treatments were moderate, and the caseload small. Sullivan and an ob-gyn worked in tandem with women who were HIV positive and pregnant. Often the pregnancies were accidental and the prognosis grim. Either the child would be born with HIV, went the conventional wisdom, or the mother might not live to care for the child. However wished for or wanted the child, often the women made the decision to terminate the pregnancy.
But then something funny started happening. The drugs got better. Fewer women had to make that gut-wrenching decision. The women weren’t focused on their immediate health. As HIV became a chronic, treatable illness, they wanted to know how to have babies safely. On this Mother's Day, I was reminded of this story, that Sullivan told me, and it seemed appropriate to share. It's an important piece of the #HIVLoveWins story, and an important history that we don't talk about often enough.
She told me more. Her caseload shifted from only HIV-positive women. Her HIV-positive male patients started bringing their girlfriends and wives into the clinic, wondering if they could have a child—and if there were a way to keep both mother and child negative. This was a tricky question. Even though there were methods to protect the HIV-negative women from the virus, most of those methods are expensive. They range from adoption and using donor sperm to assisted reproductive technology. Methods such as intrauterine insemination, which involves injecting partner sperm into a woman’s cervix, to in-vitro fertilization (IVF), which involves harvesting several eggs from the woman and placing the sperm and eggs together in a lab setting. And then there's IVF with a procedure called ICSI, which. For the couples who decided to use the HIV-positive man’s sperm, none of this could be done without also paying a few hundred dollars for a procedure called sperm washing. The procedure separates the seminal fluid, which holds the virus, from the sperm.
For Sullivan’s patients, who were mostly low-income and sometimes precariously housed, none of those pricey procedures were an option. She tried to make them available anyway, bootstrapping a low cost, in-house sperm washing/IUI procedure from essentially donated labor and on-the-fly IUI training. Most of the time, she didn’t have anything to offer them. As a woman starting her own family at that time, not being able to help them was frustrating.
“I know what it’s like to want to start a family or expand a family and come across challenges," she told me. "Their challenges were much more enormous than mine. I felt a connection with them. Having a family with someone you love is not the primary reason, but it’s one of the main reasons to get married.”
So when results started coming in from research showing that some HIV medications, used by the HIV-negative partner, could stave off infection, Sullivan became hopeful. This, she thought, could be the long-awaited solution for her patients—and herself as a doctor.
Early news from studies of men who have sex with men (MSM) and transwomen showed some efficacy, but early studies on cis-women weren’t so positive. In the studies of single straight cis-women in Africa, they found the treatment, called pre-exposure prophylaxis, didn’t work but not because the medication didn’t work. It didn’t work because the women didn’t take it.
All this left Sullivan in a quandary: How to counsel the increasing number of straight women in relationships with HIV-positive men on how to have a baby.
“There is just not a lot of in-depth awareness of reproductive health for women with HIV-positive men, or HIV-positive women,” she said. “Some people say, ‘How can you even advocate that, that HIV-positive people have children?’ It shows a real lack of understanding of how the field has moved forward.”
On this Mother's Day, I offer congratulations to the couples who are courageously in love, and who have built families in whatever ways they choose--whether it's adoption, reproductive technology, PrEP or careful condomless sex. Here's to the courage that makes motherhood possible for these families.