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Preconception Care and Contraception for HIV-infected Women

Preconception Care and Contraception for HIV-infected Women. Deborah Cohan, MD, MPH Associate Professor University of California San Francisco. I have no financial disclosures. Learning Objectives. Describe the elements of a preconception evaluation for HIV+ women who desire conception

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Preconception Care and Contraception for HIV-infected Women

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  1. Preconception Care and Contraception for HIV-infected Women • Deborah Cohan, MD, MPH • Associate Professor • University of California San Francisco

  2. I have no financial disclosures.

  3. Learning Objectives • Describe the elements of a preconception evaluation for HIV+ women who desire conception • Discuss counseling points to review during a preconception visit with an HIV+ woman • Describe a safe method of conception for HIV+ woman/HIV- man serodiscordant couple. • List the pros/cons of various contraceptive methods for HIV+ women

  4. What are reproductive rights? • The basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. World Health Organization

  5. amfAR, n=4831 US adultsemail survey (2008)

  6. HIV+ women internalize stigma around conception • Women Living Positive Survey • n=700 HIV+ women on ARVs for 3+ yrs • 59-61% believed could have children if appropriate care • 59% believed society strongly urges not to have children • Caucasian (67%) vs. Hispanic (53%), (p < 0.05) • South (66%) vs. Northeast (52%) or Midwest (55%), (p < 0.05) • ID (62%) vs. FP/GP (62%) vs. NP or PA care (48%) (p < 0.05) Squires et al. AIDS PATIENT CARE and STDs 2011

  7. Fertility desires among HIV+ ¹Chen FamPlannPersp 2001, ²Stanwood Contraception 2007, ³Ogilvie AIDS 2007, 4Oladapo J Natl Med Assoc2005, Finocchario-Kessler AIDS Behav 2010

  8. Chen et al. Family Planning Perspectives, 2001 • “Being infected with HIV dampens but does not come close to eliminating individuals’ desires and intentions to have children.”

  9. Unintended pregnancy Finer/HenshawPerspec Sex Repro Health 2006; Massad AIDS 2004; Koenig AJOG 2007; FloridiaAntivirTher 2006

  10. Establish reproductive desires • WHO? • Every reproductive-aged women • Even if amenorrhea, no current male sexual partner • WHEN? • Early and Often • Puts the issue “on the map” • New life circumstances/partners, new medications (drug-drug interactions), new developments in HIV

  11. I want to get pregnant!

  12. Preconception Care • HIV history • Nadir/current CD4, viral load, ARV hx, resistance • Disclosure, adherence • Serostatus of children • Medication review (HIV, non-HIV, OTC) • Medical hx • Asthma, DM, HTN, obesity, HBV, HCV • Reproductive hx • STIs, dysplasia/Tx, prior pregnancy outcomes, sexual, contraceptive, menstrual, infertility hx • Social hx/Habits • EtOH, drug, nicotine, nutrition/exercise • Violence/abuse, social support • Family genetic history

  13. HIV-related counseling • Pregnancy impact on HIV • ARV efficacy • Sexual transmission (92%  with ARV) • Perinatal (0.4% if VL <500 at delivery) • Adherence and disclosure • ARV safety • Avoid preconception/1st trimester EFV • Caution with d4T/ddI • Avoid NVP initiation if CD4 > 250 • ARVs and PTD • Preconception/1st trimester: OR 1.71 (1.09-2.67) • Pros/cons of ARV initiation preconception vs. 2nd trimester Donnell Lancet 2010; Tubiana CID 2005; Hitti JAIDS 2004; Shapiro NEJM 2010; Kourtis AIDS 2007

  14. OI-related counseling • <200: TMP-SMX •  risk NTD, CV and urinary defects • Folic acid (mostly 6mg) • CV anomalies OR 1.24 (0.94-1.62) • Multiple anomalies OR 6.4 (none) to 1.9 (+ folic acid) • BUT…  risk TMP-SMX prophylaxis/Tx failure • Defer pregnancy until d/c TMP-SMX? • <50: Azithromycin vs. clarithromycin DHHS Guidelines 2010 (aidsinfo.nih.gov); Hernandez-Diaz 2000; Czeizel 2001; Hernandex-Diaz 2001; Safrin 1994; Razavi 2002

  15. Other preconception counseling • Co-infections • HBV (2 active NRTIs) • HCV • 10-20% transmission • RBV = category X • Avoiding incident CMV, Toxo • Prenatal/postnatal care • Genetic testing • Delivery route (TOL if VL < 1000) • Infant feeding, AZT prophylaxis, HIV testing • Optimizing health • Vaccination, diet/exercise, smoking/drug use • Psychosocial referrals • Contraception Tovo CID 1997, Gibb Lancet 2000, Alter 2006; Polis CID 2007; Ng-Giang 2010

  16. How to manage serodiscordant couples?

  17. HCSUS, (1996 data) Currently married or with heterosexual partner Many HIV+ heterosexual adults in serodiscordant relationships HIV+ MEN HIV + WOMEN 54% 52% Chen et al. Family Planning Perspectives, 2001

  18. Safe conception:HIV+ woman and HIV- man • 1. Predict ovulation (kit, BBT, cervical mucus) • 2. Ejaculate into cup or spermicide-free condom • 3. Home insemination with 5-10 cc syringe + + or

  19. I don’t want to get pregnant!

  20. A case…. • 32 yo G4P1T3 coming for her routine HIV appointment. • On TDF/FTC/DRV/r • Irregular menses but no other complaints • She is sexually active with HIV-negative male partner of 4 months. • Uses condoms “always”

  21. Contraception Failure (1st Year) Hatcher: Contraceptive Technology 16th Edition 1994.

  22. What method of contraception would you recommend? • Combined oral contraceptive pill • Vaginal ring • Depo-provera (DMPA) • Intrauterine device (IUD) • IUD or DMPA

  23. ARVs and Oral Contraceptive Pills  HORMONE LEVELS EFV (600mg): NG AUC  NVP APV DRV/r LPV/r NFV RTV TPV/r NO CHANGE • TDF (FEM-PrEP?) • RAL  HORMONE LEVELS • EFV (400mg): EE AUC  • ETR • ATV • IDV El-IbiaryEur J ContraceptReprod Health Care. 2008, SevinskyAntivirTher2011, Anderson Br J Clin Pharmacol. 2011

  24. Depo-medroxyprogesterone acetate (DMPA) and ARVs • No Δ DMPA levels among women on: • NFV • NVP • EFV • Other PIs? • No Δ CD4 or viral load with DMPA Cohn Clin Pharm Ther 2007; Nanda FertilSteril 2008; Watts Contraception 2008

  25. Hormonal contraception and HIV progression Any impact probably mitigated by HAART Baeten AIDS 2005, Richardson AIDS 2007, Stringer AIDS 2009, Morrison JAIDS 2011

  26. IUDs are safe for HIV+ women • No evidence of  infectious complications • 156 HIV+, 493 HIV- (Kenya; Copper IUD) • Overall complications @ 24 mos: HR 1.0 (0.6-1.6) • PID: 2% for HIV+ vs. 0.4% for HIV- (p=0.09) Morrison BJOG 2001; Sinei Lancet 1998; Richardson AIDS 1999; Heikinheimo Human Repro 2006

  27. IUDs are safe for HIV+ women • No evidence of  infectious complications • 156 HIV+, 493 HIV- (Kenya; Copper IUD) • Overall complications @ 24 mos: HR 1.0 (0.6-1.6) • PID: 2% for HIV+ vs. 0.4% for HIV- (p=0.09) • No evidence of  genital tract shedding of HIV • Copper IUD n=98 (Kenya): 4 mos s/p insertion: OR 0.6 (0.3-1.1) • LNG-IUS (Mirena) n=12: no difference pre vs. post-insertion • 10/12 on HAART • On-going studies Morrison BJOG 2001; Sinei Lancet 1998; Richardson AIDS 1999; Heikinheimo Human Repro 2006

  28. IUDs are safe for HIV+ women • No evidence of  infectious complications • 156 HIV+, 493 HIV- (Kenya; Copper IUD) • Overall complications @ 24 mos: HR 1.0 (0.6-1.6) • PID: 2% for HIV+ vs. 0.4% for HIV- (p=0.09) • No evidence of  genital tract shedding of HIV • Copper IUD n=98 (Kenya): 4 mos s/p insertion: OR 0.6 (0.3-1.1) • LNG-IUS (Mirena) n=12: no difference pre vs. post-insertion • 10/12 on HAART • On-going studies • WHO Medical Eligibility Criteria category 2 • Benefits generally outweigh theoretical or proven risk • AIDS, but NOT “clinically well on ARV” category 3 for insertion • Not recommended unless other methods not available/not acceptable Morrison BJOG 2001; Sinei Lancet 1998; Richardson AIDS 1999; Heikinheimo Human Repro 2006

  29. Caring for an HIV+ woman of reproductive age? • Comprehensive sexual hx and determine fertility desires • Preconception visit = harm reduction • Validating fertility desires • Optimize woman’s health • Prevent perinatal and sexual HIV transmission • Contraception visit • Consider drug-drug interactions with hormones • Promote long-acting reversible methods • IUD = underutilized option

  30. National Perinatal HIV Hotline (24/7) • (888) 448-8765 • UCSF RID Pager (24/7) • (415) 443-8726 • ReproIDHIV listserv • Sponsored by NCCC, IDSOG, UCSF RID Fellowship • Want to join? contact Shannon Weber at: sweber@nccc.ucsf.edu

  31. Thank you! “Do we have to fill our patients’ lives with years or those years with life?” Augusto Enrico Semprini

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