PRECONCEPTION AND REPRODUCTIVE HEALTH FOR WOMEN AND MEN LIVING WITH HIV

2012 FTCC Meeting

Shannon Weber, MSWJudy Levison, MD, MPHMary Jo Hoyt, MS, FNP

What is preconception care it and why should we care about it?

Shannon Weber, MSW

Disclosures

We have no financial disclosures.

Goals of preconception care in the context of HIV infection

Prevent unintended pregnancy Prevent HIV transmission to partner Optimize maternal & paternal health Improve maternal and fetal outcomes Prevent perinatal HIV transmission

ACOG Practice Bulletin No 117; December, 2010

Importance of preconception care

Women and men living with HIV want to have children. Many pregnancies among HIV-infected women are unintended. Contraception is under utilized, including men in the

conversation. Women and men face barriers related to stigma and conception

with serodiscordant partners Preconception counseling and care not addressed pro-actively Reproductive health care often not a priority for patients or

providers

Estimated number of births to women living with HIV infection, 2000-2006

5500

6000

6500

7000

7500

8000

8500

9000

2000 2001 2002 2003 2004 2005 2006

High Estimate Low Estimate

Office of Inspector General (Fleming), 2002 Whitmore, et al. CROI, 2009

amfAR email survey of US adults, n=4831 (2008)

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

Squires et al. AIDS PATIENT CARE and STDs 2011

Reduce stigma, normalize desires

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

Hey, Mom………

Unintended pregnancy

Finer/Henshaw Perspec Sex Repro Health 2006; Massad AIDS 2004; Koenig AJOG 2007; Floridia Antivir Ther 2006

US general population 49% pregnancies unintended

US, WIHS

232 HIV+ women 77% pregnancies while using contraception (vs. 60% HIV-)

US 1090 HIV+ adolescents

83.3% unplanned49-52% HIV status known

Italy 334 HIV+ on ARV 57.6% unplanned

Men’s sexual and reproductive health

Provides guidance to programs that plan to develop or enhance clinical services for male clients

Defines the scope of male sexual and reproductive health services and set standards for their content and design

Provides a wide range of prevention, health education and treatment issues related to male health and sexual function

http://www.cicatelli.org/titlex/downloadable/MaleGuidelines2009.pdf

HIV heterosexual serodiscordant couples

Estimated to be 140,000 US serodiscordant couples

About half desire children Lampe, et al Am Journal Of Obst and Gyn, 204(6), 488e1-8, 2011

Increasing call volume to the National Perinatal HIV Hotline (888-448-8765) from clinicians and patients seeking safer conception options.

Every interaction is an opportunity

To discuss HIV status or testing To discuss reproductive health desires

Preconception Contraception Safer conception

The stories in our lives do not always coincide with the reminders in the medical health record.

Start the conversation. Stay open. Repeat.

Primary HIV care includes reproductive health

If we succeed at integrating preconception and family planning into primary care model Every HIV-exposed pregnancy will be planned and

well-timed There will be no HIV transmission to infants or to

uninfected partners The health of all HIV-affected parents and infants will

be optimized

Preconception Care Case Studies

Judy Levison, MD, MPH

Science: There is evidence that individual components of preconception care work:

Rubella vaccination HIV/AIDS screening Management and

control of: Diabetes Hypothyroidism PKU Obesity

Folic acid supplements Avoiding teratogens:

Smoking Alcohol Oral anticoagulants Accutane

Role Play!

Case 1—Roberta

30 year-old woman tested HIV+ positive during her recent pregnancy and started HIV treatment

CD4 (T-cells) have improved on treatment and her viral load is undetectable

Infant is 4 months old and HIV-uninfected Plan:

Renew medications today, check labs before she returns for a check up in 3 months.

Encourage adherence Remind to use condoms

Case 1—Roberta…

You ask about contraception.

She previously used oral contraceptives and asks about restarting them.

How do you counsel her?

Focus on couples where a partner is HIV-positive How do you know if your patient and his/her partner

are considering pregnancy? You have to ask! If they do NOT desire pregnancy, then ask what they

are doing for contraception Let’s review contraception and preconception

counseling for couples who are infected or affected by HIV

Condoms

The one method that protects against STDs and provides contraception

How do your clients feel about using male condoms? Female condoms?

Male condoms

Female condoms

Condoms

However, 15% failure rate in preventing pregnancy Many couples (even serodiscordant couples=one

partner HIV+ and one partner HIV-) use condoms off and on, rather than always

So, a second method is recommended

Oral contraceptives

Same criteria as for HIV- women if woman is NOT on antiretroviral therapy (ART)

Problematic for HIV+ women on ART Ritonavir, lopinavir, nelfinavir, amprenavir, and

darunavir (PIs) and nevirapine (NNRTI) increase metabolism of ethinyl estradiol and/or norethindrone, thus lowering efficacy of OCPs

Atazanavir (PI) and efavirenz (NNRTI) increase ethinyl estradiol levels (clinical impact unknown)

ACOG (2010), Gynecologic care for women with human immunodeficiency virus. Practice Bulletin #117.

Contraception

Other hormonal options

Patch (Ortho Evra), vaginal ring (Nuva Ring), and transdermal implant (Implanon) Warnings are similar to OCPs regarding drug-drug

interactions However, in theory, they avoid the “first pass” effect of

liver metabolism that may occur with oral agents and should not be subject to the same limitations as OCPs

Depo-Provera: OK (concerns that DMPA might increase HIV viral shedding have not been supported)

Conference on Retroviruses and Opportunistic Infections (March 2012), Seattle.

Intrauterine devices (IUDs)

No known drug interactions No increase in shedding of HIV 2 types

Copper (Paragard) works for 10 years, may be associated with heavier menses, periods regular)

Levonorgestrel IUD (Mirena) works for 5 years, reduces menstrual blood loss (is FDA-approved as a treatment for menorrhagia), periods scant and not regular

IUDs(2)

Permanent sterilization

Laparoscopic tubal ligation

Essure (hysteroscopically placed coils in tubes)

Postpartum tubal ligation

Vasectomy

Laparoscopic tubal ligation

Essure

Postpartum tubal ligation

Vasectomy

Integrating preconception and HIV care

Challenges: Lack of comfort and/or knowledge

Actual or perceived lower level of priority compared to other issues

Time constraints

Role of the primary care provider not entirely clear

The Serodiscordant Couple

Role Play!

Case 2--Julia

Case 2—Julia …

You ask Julia if she wants to have another child. She says, “Yes.” You ask, “When?” She says, “ Now.”

How do you counsel her?

How do YOU feel about her wanting to get pregnant?

That is ridiculous—who will take care of your children if you die and you would risk having an HIV+ child?

I, as your health care provider, will be angry if you get pregnant.

I need to think about this. You have every right to do this. Let’s work together

to do it right.

The first two responses may have been appropriate before we saw the successes of the HAART era

But in 2011: Perinatal transmission is <1-2% Men and women with HIV can expect to live to see their

children grow into adulthood

Preconception counseling

If a woman is not on ARVs, consider starting them prior to attempting conception

If a woman is on ARVs and is considering pregnancy Substitute other ARVs for efavirenz (Sustiva) because

of possible risk of neural tube defects (NTDs) Recommend folate or prenatal vitamins

preconceptionally to reduce chance of NTDs

Serodiscordant couples

If the woman is HIV+ and the man is HIV-, discuss the options of: Ovulation predictor kits Home insemination (“turkey baster method”)

Ovulation predictor kits

These replace the old basal body temperature charts

When the time is right, the choices are:

Home insemination with partner’s semen

The “turkey baster” method*A needle-less syringe works fine

Alternatives

Insemination in a doctor’s office with partner’s semen Having penile/vaginal intercourse only during the 24 hours

after the LH surge and using condoms the rest of the month—if this is the plan, then placing the woman on ARVs prior to attempted conception will further protect her partner

Post or pre-exposure prophylaxis for male? If yes, how many doses?

Baeten, J. and Celum, C. 2011. Antiretroviral pre exposure prophylaxis for HIV prevention among heterosexual

African men and women: The Partners PrEP Study. Int. AIDS Society, Rome.

And one more word about condoms…

If we do not broaden our discussions around reproductive health (leaving it at "use condoms“), many individuals will do what they will do at home in order to achieve pregnancy

It’s much better that they conceive with support and knowledge of safe options. We don’t want clients to feel they have to hide their desire to have children.

Role Play!

Case 3—Richard

Case 3—Richard

You ask Richard whether his fiancee has been tested for HIV He says, “Yes, and she is HIV-negative.”

You ask whether they are thinking about having children He tells you, “Yes, sooner rather than later.”

How do you counsel him?

Serodiscordance

If the man is HIV+ and the woman is HIV-, consider: Maximal viral suppression of the male Ovulation predictor kit/ timed insemination with

washed sperm Intracytoplasmic sperm injection (ICSI) Ovulation predictor kit/timed intercourse Post-exposure prophylaxis (PEP) or pre-exposure

prophylaxis (PrEP) for female Donor insemination

Sperm washing

Cost is in the $1500 range Not widely available

http://aids.about.com/cs/womensresources/a/washing.htm

http://www.thebody.com/content/art911.html

Has the time come for natural conception in the context of full viral suppression?

Barreiro 62 serodiscordant couples HIV+ partner on ART and VL < 500 No transmission of HIV

HPTN 052 96% reduction in transmission of HIV among

serodiscordant couples (ARVs started if CD4 350-500)

Barreiro et al. (2007) Is natural conception a valid option for HIV serodiscordant couples? Human Reproduction, 22 (9), 2353

Cohen, M. et al. 2011. Prevention of HIV-1 with early antiretroviral therapy. NEJM 365: 493-505.

What if both partners are HIV-positive?

When a couple is not attempting conception, we recommend condoms to avoid superinfection and sharing of antiretroviral resistant virus

If pregnancy desired: Ovulation predictor kit, maintaining an undetectable viral load, and once monthly unprotected sex is a reasonable approach

How can contraceptive and preconception care be integrated into routine care?

Mary Jo Hoyt, MSN

Integrating preconception and HIV care

Simplify: Ask patients about reproductive plans Discuss the importance of planning for pregnancy Ensure contraceptive needs are met Develop a preconception plan in consultation with

experts

Integrating preconception and HIV care

Co-locate/integrate OB-GYN and HIV services

Develop collaborative relationships, bilateral communication, formal linkages, referral indications and practice guidelines

Consider development of a peer educator program

Provide training and support

General preconception care resources

CDC preconception care site: http://www.cdc.gov/ncbddd/preconception/

Preconception care advocacy group: http://www.beforeandbeyond.org . Includes 2011 preconception summit information Professional education materials Published articles

Number 117, December 2010Gynecologic Care for Women With Human Immunodeficiency Virus

Guidelines

Guidelines

Training

Training

FXB Center will host Preconception Care webinar. Self-study modules will also be available [Coming soon] Preconception care in the context of HIV

infection Contraceptive care for women/couples

living with HIV infection Safer conception for HIV-discordant

couples

Webinar

Self-study modules

• http://www.fxbcenter.org/• http://www.aids-etc.org

Support tools: Patient Brochure

Support Tools: EPIC Template

Are you interested in having a child? When do you wish to conceive?

Currently 6 mos-1yr, 1-2 years; >2years Are you currently using condoms? Are you currently using contraceptive other than condoms:?

If Yes what method: If no are you seeking pregnancy:

Would you like information on planning a safe pregnancy that may reduce the risk of HIV transmission to your partner and your baby?

Do you know and understand your CD4 count and viral load?

Support Tools: EPIC Template (2)

Do you understand the importance of being in optimal health before becoming pregnant?

Counseling elements when definitely considering pregnancy: Antiretroviral medications that are not recommended

in pregnancy (e.g. EFV) Options for discordant couples: Referral to Women’s Service: Preconception

Counseling

Support tools: Client questionnaire

Support tools: Provider Checklist

Support tools: Counseling Guide

A counseling guide for providers with suggested scripts for discussing fertility desires and preconception care with women of reproductive are living with HIV.

Support tools: Guidelines for Use of ARV Therapy in Pregnancy

Clinical tools: Guidelines for Use of ARV Therapy in Pregnancy

Expert consultation and information updates

The ReproIDHIV listserv is a forum for discussing clinical cases, finding patient referrals, sharing protocols and upcoming events, and networking with colleagues.Sponsored by:

UCSF/HRSA National HIV/AIDS Clinicians’ Consultation Center Infectious Disease Society of Obstetricians and Gynecologists UCSF Fellowship in Reproductive Infectious Disease

http://www.nccc.ucsf.edu/

To be added to the listserv contact: Shannon Weber sweber@nccc.ucsf.edu

Expert Consultation (at no cost)

Perinatal HIV Hotline National Perinatal HIV Consultation and Referral

Service 1-888-448-8765

Warmline National HIV/AIDS Telephone Consultation Service 1-800-933-3413

Speaker contact information

Shannon Weber, MSWNational HIV/AIDS Clinicians' Consultation Center sweber@nccc.ucsf.edu

Judy Levison, MD, MPHBaylor College of Medicinejlevison@bcm.edu

Mary Jo Hoyt MSN, FNPFXB Center, UMDNJAETC National Resource Centerhoyt@umdnj.edu