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Transcript of William Short MD, MPH Assistant Professor of Medicine, Division of Infectious Diseases Jefferson...
William Short MD, MPHAssistant Professor of Medicine, Division of Infectious Diseases Jefferson Medical College of Thomas Jefferson [email protected]
Preconception care in the setting of HIV infection
This teleconference is made possible by the Cooperative Agreement #5U65PS000815-03 from the Centers for Disease Control and Prevention
Special thanks to AETC, Title X and CDC EMCT partners
The views expressed by the speakers and moderators do not necessarily reflect the official polices of the Dept. of Health and
Human Services nor does mention of trade names or organizations imply endorsement by the U.S. Government.
Module objectives
Explain the goals and discuss the importance of preconception care in the context of HIV.
Demonstrate preconception counseling for women and couples with HIV, including special considerations for preconception counseling for HIV-infected men.
Describe preconception assessment and interventions for women living with HIV.
Module objectives
Explain the role of the HIV primary care provider in preconception counseling and care
Discuss models of integration of preconception care
HIV+ women internalize stigma around conception
Women Living Positive Surveyn=700 HIV+ women on ARVs for 3+ yrs59-61% believed could have children if appropriate care59% 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. (2011) AIDS patient care and STDs
Fertility desires and intentions
Studies of fertility desires and intentions have consistently shown that many women living with HIV want to have children.
Survey of >1400 HIV+ adults in care in 1998: 28% of bisex/heterosex men 29% of women want children in future
Survey of 450 HIV+ women in the UK in 2011 75% stated they wanted more children
Fertility desires and intentions
Positive influence Negative influence
• Younger age• No children• Antiretroviral therapy• Interventions for PMTCT• Partner’s/family
members’ wish for children
• HIV-related stigma
• Already having one or more children• Personal health concerns• Concerns about infecting partner• Concerns about infecting child• Negative or judgmental attitudes of
health workers, family• HIV-related stigma
Factors Associated with fertility desires
Contraceptive Use Among US Women with HIV
Women's Interagency HIV Study (WIHS):
In over 30% of these visits, HIV-infected women reported not using any form of contraception.
Massad et al. (2007)J Women’s Health
Estimated # of births to women with HIV
5500
6000
6500
7000
7500
8000
8500
9000
2000 2001 2002 2003 2004 2005 2006
High Estimate Low Estimate
Fleming (2002) Office of Inspector General Whitmore, et al. (2009) CROI
Live birth rates among HIV+ women before and after HAART availability
Comparison of live birth rates 1994-1995 (pre-HAART era) and 2001-2002 (HAART era) in HIV+ and HIV- women 15-44 years
Largest difference (306% increase) was seen in women >35 years old
In HAART era, 150% increase in live birth rate among HIV+ women vs. 5% increase among HIV- women
Sharma, et al. AJOG 2007
Preconception care
“Interventions that aim to identify and modify biomedical, behavioral and socials risks to a women’s health or pregnancy outcomes through prevention and management”
Early prenatal care is not enoughCDC. MMWR 2006;55:1-23
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
Unintended pregnancy
Finer and Henshaw (2006) Perspec Sex Repro Health; Massad (2004) AIDS Koenig (2007) AJOG ; Floridia (2006) Antivir Ther
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
Are HIV providers discussing reproductive desires?
Women Living Positive Survey (n=700, ARVs for 3+ years) 48% previously pregnant or considering pregnancy
were never asked about their pregnancy intentions (n=227)
57% currently or previously pregnant or considering pregnancy had not discussed treatment options (n=239)
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
optimizedSquires et al (2011) AIDS pt care and STDs
Establish reproductive desires
WHO? Every reproductive-aged woman and man Even if they do not have a current sexual partner
WHEN? At initial evaluation Intervals throughout the course of care
Conduct preconception counseling
Conduct preconception counseling when: There is an expressed interest in conceiving There is nonuse/inadequate use of effective
contraception There is a change in relationship or personal
circumstances
Conduct preconception counseling
Conduct preconception counseling when: She is taking medications with potential reproductive
toxicity or interaction with hormonal contraception She is at risk for unintended pregnancy There is new information about pregnancy and HIV She plans enrollment in a clinical trial
Conduct preconception counseling
Impact of pregnancy on HIV and impact of HIV on pregnancy
Risk factors for MTCT and strategies to reduce those risks ARV medications C-section Avoidance of BF
Risks/benefits of HIV-related medications
Disclosure of HIV diagnosis
Partner testing Safer conception
options
Conduct preconception counseling
Address alcohol, drugs and/or tobacco use
Recommend avoidance of OTCs
Consider delaying pregnancy until health is optimized
Optimize preconception health
Screen for:Syphilis
Refer for:Genetic screening, based on historyContraception, as needed, to delay pregnancy while health issues are addressed
Provide:Folic acid 400 mcg dailyImmunizations, as needed, for:
hepatitis B rubella varicella
Optimize preconception health
Perform clinical staging, CD4 testing and viral load as indicated
Assess and treat opportunistic infections
Assess need for prophylaxis against OIs
Optimize treatment/control of other chronic diseases
Review all medications for safety in pregnancy
Consider ARV treatment
Initiate/modify ARV treatment for women who need it for their own health:
Consider the regimen’s effectiveness for treatment of HIV, hepatitis B disease status, potential for teratogenicity and possible adverse outcomes .
Adjust ARV regimens to exclude efavirenz or other drugs with teratogenic potential during the preconception period.
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
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
Integrating preconception and HIV care
Provide training and supportGuidelines: Perinatal HIV guidelines and ACOG practice bulletin clearly describe components of preconception care
Training curriculum and job aids: Links to materials will be sent to webinar participants
Integrating preconception and HIV care
Simplify approach by emphasizing core principles:
Ask clients of reproductive age about their reproductive plans
Discuss the importance of planning for pregnancy to ensuring
preconception health/safer conception
Ensure contraceptive needs are met
Develop a preconception plan for women/couples who want to
become pregnant or who are not using adequate contraception
Integrating preconception and HIV care
An informational brochure for clients on preconception health and the importance of preconception care
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
Thank you!
Contact the FXB Center with questions or comments, or for a copy of the slide set:
Mary Jo [email protected]