When Poppy Morgan* walked in to work on her first day on the job in a new city, she wasn’t expecting to fall in love. But then Ted Morgan, a tall, lanky Californian with sandy blond hair and pink cheeks, held the door open for her and everything changed.
“He held out his hand to shake hands and said, ‘Hi, welcome. I’m [Ted],” she said. “I was looking into his amazing blue eyes and I remember thinking, ‘This is the guy.’ I just knew it from the moment I met him.”
This was not a welcome realization. For one thing, it was her second day in San Francisco and she was still getting her bearings. For another, she already had a boyfriend. Besides, she worked with the guy.
The fact that Ted was HIV-positive, diagnosed in 1995, didn’t come into play until the two started dating a year and a half later. But even that didn’t deter her dreams of pink-cheeked babies that had already started appearing in Morgan’s head. This was, after all, a woman who, as a child in a Chicago suburb, turned spoons and forks into babies, tucking them in to the cutlery drawer with a prayer that they sleep soundly. She always knew she wanted to be a mother, and now she wasn’t sure how it would happen. But she knew, somehow, it would.
|Book cover for HIV and Baby Makes Three|
A year after Poppy met Ted, a 26-year-old man picked up the phone in his apartment in upstate New York and dialed a number he found on the Internet.
“Hi,” he said into the receiver. “This is Dan Hartmann.”
On the other end of the line, in Oakland, California, Susan Slingluff was running late to meet a friend for a party. But Hartmann’s voice stopped her.
“I was excited to hear from him,” she said. “I was also thrilled that he was still alive.”
The pair had known each other since ninth grade. In high school, they’d gone to prom together—“as friends,” Slingluff said. Hartmann had even attended Slingluff’s 21st birthday party five years before. He’d been healthy then. But with HIV, you never could tell. Hartmann contracted HIV at 12, when he received a tainted blood product for his hemophilia.
But this was 2000, Hartmann was doing well on the cocktail of drugs known as highly effective anti-retroviral treatment (HAART), and he never forgot Slingluff. They never dated in high school, much to Hartmann’s chagrin, he told me.
Slingluff was three hours late to the party. Their hours-long phone calls became routine.
Soon, the couple started talking about meeting face to face. Very quickly, they agreed, it was clear that this wasn’t a casual flirtation. What that meant for her fertility, Slingluff didn’t know. They weren’t discussing children yet, but Slingluff did wonder if choosing him would mean forfeiting the chance to have a baby.
“Unfortunately, no one knew,” said Slingluff. Hartmann’s HIV doctor, whom the couple consulted as they discussed getting serious, didn’t have much to offer besides small pilot studies with inconclusive results. And Slingluff didn’t bother to consult her general practitioner, assuming he wouldn’t know more than Hartmann’s doc. The U.S. Centers for Disease Control and Prevention’s (CDC) official stance was simple: Unprotected sex leads to the spread of HIV. HIV-positive people should never, under any circumstances, have sex without a condom. And the couple, when they did meet and consummate their relationship, stuck to that to the letter of the law. Public health officials will tell you that this never happens, but the couple swears they never, not once, had sex without a condom. They respected public health campaigns, even if it meant that they couldn’t have a baby the old-fashioned way.
That doesn’t mean Slingluff didn’t think about unprotected sex in the service of having a baby, though. After all, even condoms are only 80 to 85 percent effective against the spread of HIV. Not surprisingly, Slingluff spent a lot of time thinking about risk. As someone in a relationship with someone with HIV, she was never going to be 100 percent safe from the virus. You get used to that, she said.
“What I wanted to know was the risk level,” she said. “I wanted to know what I was dealing with. And no one could tell us.”
As the Hartmanns were wondering and the Morgans were courting, across the country in North Carolina, a team of investigators were setting out to examine the issue. Dr. Myron Cohen has a lot of titles: associate vice chancellor for global health; J. Herbert Bate Distinguished Professor of Medicine, Microbiology and Immunology; public health director at the Institute for Global Health and Infectious Disease; chief of the Division for Infectious Diseases; and director of the Center for Infectious Diseases, all at the University of North Carolina Chapel Hill.
But in 2000, what he was, mostly, was the head of a team of investigators who were looking into the mechanics of HIV transmission. See, HIV is tricky. HIV targets and kills precisely the cells of the immune system that are designed to attack it, leaving our bodies’ virtually defenseless. And the virus is constantly mutating in order to evade both the immune system and the drugs designed to treat it.
Despite what most of us believe from popular culture, the chance of someone passing on HIV isn’t 100 percent all the time. It’s pretty high—about one in 1,000 for unprotected receptive penile-vaginal sex and about 5 in 1,000 for unprotected receptive anal sex. But people with HIV are more infectious some times than others, depending on the amount of virus in their system. The virus can show up in the blood at one level—called the viral load—but in the seminal fluid and vaginal secretions at another level. That makes knowing how infectious you are tough.
When the first effective HIV medications came out in 1996, it excited everyone. HAART drug cocktails were the first treatment able to slow or stop the replication of HIV inside the cell. Right away, scientists wondered: If there’s less virus in the blood and the semen, does that mean someone with HIV is less infectious? Could treatment stop the spread of the virus? It seemed logically true, but no scientist, and certainly not Cohen, was willing to make any bets without research.
“I’d never done a big clinical trial” in 2000, said Cohen when I called him at his office recently. “If you’d told me in 1990 that I would lead a clinical trial in nine countries, I would have told you it seemed impossible.”
But it wasn’t. By 2000, Cohen began to assemble what has been, to date, the largest study of its kind. He contacted sites in Africa, South America, Asia and the U.S. to collaborate on the study and recruit couples in stable relationships willing to submit to questions about their HIV status, STDs and other factors. The idea was to separate these couples into two groups. In one, the HIV-positive partner would receive HAART immediately. The HIV-positive partner in the other group would get it later—when immune function dropped but before infection or immune system failure. Couples in both groups were offered condoms and urged to use them—which, Cohen said, “They don’t, even when you ask them to.”
In order to figure out how beneficial treatment is, the study would also try to remove variables that can increase infectiousness, including screening and treating couples for gonorrhea and chlamydia. At the same time, researchers would carefully monitor the HIV-positive partner to make sure he was taking his medications as prescribed. (The study included HIV-positive men and women, but for the sake of this story, we’ll discuss the HIV-positive partner as being male.) Obviously, with the study’s emphasis on condoms, it wasn’t designed to test whether couples could get pregnant safely. It wanted to answer the most salient question first: Could treatment prevent transmission?
So as 2000 wound down, Cohen and his team settled in for a long period of preparation, well aware that the National Institutes of Health, which was funding the study, could pull the plug on it at any time if it discovered that treatment didn’t prevent transmission, and HIV-negative partners were contracting the virus at high rates.
“It was,” he told me, “not at all clear to me what the results would be.”
*The Morgans asked that their name be changed, as Ted Morgan is not out to everyone about his HIV status.