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Preconception Care and Contraceptive Options for HIV-infected Women

Preconception Care and Contraceptive Options for HIV-infected Women. Erika Aaron, CRNP Feb 25, 2010. Presenter. Erika Aaron RN, CRNP, MSN Director of Women's Services Division of Infectious Diseases and HIV Medicine Drexel University Department of Medicine Philadelphia, PA 215-762-6828.

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Preconception Care and Contraceptive Options for HIV-infected Women

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  1. Preconception Care and Contraceptive Options for HIV-infected Women Erika Aaron, CRNP Feb 25, 2010

  2. Presenter • Erika Aaron RN, CRNP, MSNDirector of Women's Services Division of Infectious Diseases and HIV MedicineDrexel University Department of MedicinePhiladelphia, PA • 215-762-6828

  3. ACTG 076 & USPHS ZDV Recs CDC HIV Testing Recs ~95% reduction

  4. Estimated number of births to women living with HIV infection, 2000-2006 2006 estimate (8,650 – 8900) is ~30% > 2000 estimate (6075 – 6422) Office of Inspector General (Fleming), 2002Whitmore, et al. CROI, 2009

  5. Estimated* Number of Births to HIV-infected women in the US has increased >30% (2000-2006) *HIV estimate extrapolated from HIV-reporting states & back-calculation for # HIV-infected without AIDS, and pregnancy rate estimate from ASD study

  6. Pregnancy After Diagnosis of HIV • Pregnancy rates for HIV+ women: 6.0-8.2/100 person yr • 18% to 40% of US women become pregnant after HIV diagnosis (Stephenson 1996, Bedimo 1998) • WIHS cohort (1994-2002): • 7% reported conception annually • 77% pregnancies occurred with use of contraception • abortion less likely in HAART era (Massad 2004) • In US one-third of women and men with HIV desire to have a child in the future (Chen 2001) • HIV+ pregnant US adolescents (n=1090): HIV status known prior to pregnancy in 50%; 83.3% pregnancies unplanned -43% of these-no contraception (Koenig et al. AJOG 2007)

  7. U.S. Population, HIV/AIDS Cases, HIV-exposed Births and HIV-infected Infants by Race/Ethnicity, 2005 *HIV/AIDS Reporting System, CDC. HIV/AIDS Surveillance Report, Vol.17, 2007 **Enhanced Perinatal Surveillance, CDC, unpublished data.

  8. WIHS (Sharma, et al. AJOG 2007;196:541e1-6) Comparison of live birth rates 1994-1995 (pre-HAART era) and 2001-2002 (HAART era) in HIV+ and HIV- women 15-44 yrs Women in HAART era younger, higher CD4 counts In HAART era 150% increase in live birth rate among HIV+ women vs 5% increase among HIV- women Live birth rate higher in all age categories with largest difference (306%) seen in women >35 Yrs Among HIV+ women with more than high school education, live birth rate was approx ½ that of HIV- women in pre-HAART era but more than double HIV- rate in HAART era Birth rate higher in HAART era within each category of CD4 count Women with history of IDU were the only group in both HIV+ and HIV- women who experienced a decline in birth rates Live Births Among HIV+ Women Before and After HAART Availability

  9. Cumulative Incidence of First Pregnancy in 174 Perinatally HIV-Infected Sexually Active Girls Age >13 Years, PACTG 219CBrogly SB et al. Am J Public Health 2007;97:1047-1052 Screen for pregnancy in HIV-infected Adolescents! By age 19 years, 24.2% of sexually active girls had been pregnant at least once (6 had 2nd pregnancy, 1 had 3rd)

  10. Trends in Maternal Antiretroviral Therapy and Perinatal HIV Transmission, Women and Infants Transmission Study:1990-2004

  11. WHAT HIV + WOMEN SAY

  12. Providers.. We NEED You! We WANT and NEED inclusive and informed conversations about: • Realistic preconception options • HIV regiments that are both safe and effective for use during pregnancy • Referrals to culturally competent obstetricians that will honor our rights to have children • Vertical transmission and risk-reduction strategies before, during, and after pregnancy • Transmission to or from our partners during conception

  13. Voices of Women Living with HIV • “They say to me, If you do not have children, you are less of a woman. Although I have HIV, I want to be able to fully fulfill my role as a woman and mother.” • “It helps when I can tell my doctor what I need or what I want, like having a baby, and they listen and help me find the best plan.” • “You need to focus on staying healthy and not even begin to think about having children. You do realize that you are positive.. Don’t you?” (Provider)

  14. To Have or Not to Have • For women living with HIV, the decision to have, or not have children is essential. It is about the fundamental human needs of all women to be in control of their reproductive health and outcomes. • Lack of access to integrated Family Planning and Reproductive Health care leaves women vulnerable, without knowledge of safe and effective options and without access to services or contraceptive products to prevent unplanned pregnancies.

  15. Reliable FP options • “Women living with HIV have the same difficulty in condom negotiation that is faced by other women. Too often, women living with HIV even have heighten issues with self image, compromise discussions for love or intimacy, and experience feelings of being voiceless. That makes the necessity for reliable and consistent family planning options key.”

  16. STIGMA & Discriminationcan not be standard of care • “Women living with HIV face huge social pressures to be abstinent, abandon desires for motherhood, and confine their focus on being healthy. These messages are unrealistic, unfair, and limiting to honest and open dialogue.” Ebony Johnson,Community Advocacy, Education & Empowerment Specialist • Women need to have honest dialogues with providers who are informed, responsive, and culturally sensitive to the unique and layered needs of women living with HIV who are of child-bearing age, including family planning.

  17. HIV 101

  18. Women are more susceptible than men to contract HIV through heterosexual intercourse Factors that increase the risk of transmission Presence of STD Role of contraception Stage of disease in partner Exposure site (oral, vaginal, anal) Substance use Social/behavioral/cultural Age DHHS. HRSA Care Action. HIV disease in women of color. 1999; NIAID. NIH. Fact Sheet. HIV infection in women. 2002; Fowler MG, et al. Obstet Gynecol Clin North Am. 1997; Lazzarin A, et al. Arch Intern Med. 1991.

  19. Typical Course of HIV Infection CD4 lymphocytes HIV RNA load Clinically latent period 6–24 weeks 0.5–15 (?) years 2–3 years Infection with HIV Clinical symptoms Kempf D. IAS Conference on HIV Pathogenesis and Treatment, July 8 – 11, 2001.Original slide courtesy of Dr Sven A. Danner.

  20. Viral Loads • Quantitative PCR measures the “amount” of virus that is active. • Undetectable does not = eradication • Our goal: • low viral load • high CD4 count

  21. CD4 Lymphocyte Cell Count • To stage disease • Guide differential diagnosis • Therapeutic decision making • Normal • 500 to 1400 (mean 800 to 1050) • Influenced by • Intercurrent illness, WBC, corticosteroids

  22. Acquired Immunodeficiency Syndrome • AIDS - most advanced stages of HIV infection • Criteria is developed by the CDC • Includes: • all persons with CD4 count less than 200 • or has ever had a CD4 count < 200 • all persons with CD4 % less than 14% • anyone who has ever had an AIDS Indicator Condition (Opportunistic complication)

  23. US Guidelines for Treatment of HIV + Adults Including Pregnant Women 2008

  24. Adherence • Major determinant of degree and duration of viral suppression • Poor adherence associated with virologic failure • Optimal suppression may require >90-95% adherence • Suboptimal adherence is common

  25. Predictors of Inadequate Adherence • Regimen complexity and pill burden • Poor clinician-patient relationship • Active drug use or alcoholism • Unstable housing • Mental illness (especially depression) • Lack of patient education • Medication adverse effects • Fear of medication adverse effects

  26. Predictors of Adequate Adherence • Emotional and practical supports • Convenience of regimen • Understanding of the importance of adherence • Belief in efficacy of medications • Feeling comfortable taking medications in front of others • Keeping clinic appointments • Severity of symptoms or illness • Trust in their provider

  27. Preconception Care

  28. Concordant/Discordant Couples • The hope that HIV infected individuals can now lead “normal lives” with a chronic disease, has changed family planning practices among our clients • Dramatic decrease in perinatal transmission has changed our counseling.

  29. Goals of Preconception Care Prevention of unintended pregnancy Protection of maternal and fetal health during pregnancy Prevention of mother-to-child transmission of HIV Reduce risk of transmission to uninfected partner

  30. PRECONCEPTUAL COUNSELING • Protects against poor pregnancy outcomes • Decrease VL prior to conception • Risks and benefits of ART both to maternal and fetal health • Decrease anxiety about perinatal transmission • Psychological Readiness: decrease guilt, fear, fantasies, unresolved grief

  31. When to Discuss Pregnancy Initial evaluation: assess childbearing plans/desires Early in course of care desire for future pregnancy or uncertain nonuse/inadequate use of contraception At intervals during routine care, especially: interest in conceiving nonuse/inadequate use of contraception change in relationship medications with potential reproductive toxicity new developments in pregnancy and HIV at risk for unintended pregnancy enrollment in clinical trials

  32. PRECONCEPTUAL COUNSELING • Enter pregnancy in good health with healthy immune system • As few risk factors as possible: • smoking cessation, nutrition, drugs and alcohol • MVI for all women of child bearing age (folic acid)

  33. Recommend a genital examine of both partners prior to fertility attempts • Treatment of inflammatory genital tract conditions prior to pregnancy decreases risk of transmission. • Sexual transmission highly correlated with STDs and genital ulcerative disease. • Symptomatic STDs increase HIV shedding • Asymptomatic infections produce some inflammation and HIV shedding • GC urethritis 5-fold increase in transmission • Herpes simplex lesions 12-fold increase

  34. Recommend a genital examine of both partners prior to fertility attempts • Treatment of inflammatory genital tract conditions prior to pregnancy decreases risk of transmission. • Sexual transmission highly correlated with STDs and genital ulcerative disease. • Symptomatic STDs increase HIV shedding • Asymptomatic infections produce some inflammation and HIV shedding • GC urethritis 5-fold increase in transmission • Herpes simplex lesions 12-fold increase

  35. Decrease VL prior to conception • Avoid drugs with possible reproductive toxicity • Sustiva • Attain stable, maximally suppressed viral load

  36. Recommend the use of timed ovulation with self insemination • Self-administered artificial insemination with HIV- partner's sperm eliminates transmission risk. • Self insemination tools: • syringe • cervical cap • turkey baster. • Ovulation kits, basal body temperature and cervical mucus charts identify ovulation. • Recommend no unprotected intercourse • Reinforce the importance of consistence condom use after conception.

  37. Timed conception with no unprotected intercourse outside of conception. • If this couple opts to not use insemination tools after extensive counseling, the use of time conception with no unprotected intercourse outside of conception is cautiously recommended. • Conception is a more efficient process than heterosexual transmission. • Decrease VL prior to conception

  38. Refer the couple to a fertility center for intrauterine insemination • If available, a fertility center can provide intrauterine insemination (IUI) • Natural cycle in vitro fertilization/embryo transfer technology which bypasses the cervical barrier.

  39. Contraception

  40. Effective Contraceptive Methods are Underused in HIV Care Settings • WIHS: (1994-2005), n=2784; 26,832 visits ( J Women’s Health 2007, 16:857) • Barrier methods: 31-36% of visits • Tubal ligation: 21.-27% • Hormonal method: <10% of visits • No contraception: >30% • HIV+ less likely to use hormonal method

  41. Contraceptive Use Among US Women with HIV(Massad et al. J Women’s Health 2007;16:657)

  42. Contraceptive Use Among US Women with HIV(Massad et al. J Women’s Health 2007;16:657)

  43. CASE • Donna, a 21 year old P1G1 comes to your clinic as a walk-in pregnancy test. • She has a new partner since her last visit with you 5 months ago. • Donna has a 2 year old daughter from a previous partner • She uses condoms inconsistently. • She ran our of her Nuva ring one month ago and missed her last apt with you.

  44. Testing Results • Her pregnancy test is negative • You offer her an HIV test: the results are positive

  45. CASE • You have developed close ties with your local HIV clinic and call them to connect Donna to medical care. • They send an outreach worker to your clinic to make a personal connection with Donna. • She is scheduled to see a medical provider in one week. • The outreach worker will keep in close contact with Donna until her visit. • You recommend testing her partner and offer an apt for him to come to your clinic. • You set up an apt for her at your local HIV pediatric clinic to have her daughter tested.

  46. CASE • Donna has made a good connection with the HIV clinic. However she wants to continue to see you for her FP/GYN care. • Her CD4 count is 167/15%. She has been put on antiretroviral medications. • Atripla: efavirenz, tenofovir, emtribivine • Since her CD4 is <200 she starts PCP prophylaxis. • Her boyfriend is HIV -; Her daughter is HIV- • She reports a history of Childhood Sexual Abuse. • She requests contraception to prevent pregnancy. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. Geneva, Switzerland: World Health Organization; 2004.

  47. Contraception Considerations inHIV Women • Efficacy • Safety • Adverse effects • Effect on HIV progression • Effect on HIV transmission • Drug interactions • Convenience/ease of use

  48. Efficacy • Condoms alone have higher failure rate in prevention of pregnancy with typical use than most other methods of birth control • Typical failure rate in first year of use: male condom (15%); female condom (21%) • COC (8%); DMPA (3%); transdermal patch (8%); vaginal ring (8%); LNG-IUD–5 year (0.1%) • Diaphragm (+spermicides) (16%) • Spermicides (29%) • Sterilization: female (0.5); male (0.15%) Medical Eligibility Criteria for Contraceptive Use. 3rd ed. Geneva, Switzerland: World Health Organization; 2004.

  49. Safety • Risk of birth defects with conception on efavirenz (EFV) -containing regimens • FDA pregnancy category D • Teratogenic in primates • Retrospective case reports of CNS defects in infants of women who received EFV at conception and during the first trimester • EFV should be avoided during the first trimester, and in women at risk for becoming pregnant • Pregnancy should be avoided in women receiving EFV • Sufficient first trimester exposures to ART (excluding EFV) to detect 2 increase in defects have shown no increase in defects. Watts HD. Curr HIV/AIDS Rep. 2007;4:135-140.

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