The Peterborough AIDS Research Network & The AIDS Committee of Durham Region Central East Opening Doors Oshawa, Ontario Friday October 10 th 9:30-11:00am.

The Peterborough AIDS Research Network &

The AIDS Committee of Durham Region

Central East Opening Doors

Oshawa, Ontario

Friday October 10th 9:30-11:00am

Myth: “I’ll Never Have Children”

Mona Loutfy, MD, FRCPC, MPHInfectious Diseases Specialist & Clinical Researcher

Women’s College Research Institute, Women’s College Hospital & Maple Leaf Medical Clinic, Toronto, ON

I am HIV positive.

• HIV and pregnancy– Getting pregnant– Reproductive care– Preventing vertical transmission– Managing HIV while pregnant

Can I have a baby?

?

?

??

?

?

?

?

The Women and HIV Research Program

• I AM HIV-POSITVE, CAN I HAVE CHILDREN?

• ANSWER: YES– Increased life expectancy and

decreased illness– Reduced vertical transmission to <

0.5% with ARVs and no breast feeding; Caesarian section in some cases

BIG QUESTION #1

The Women and HIV Research Program

BIG QUESTION #2

• I AM HIV-POSITVE, I WANT TO BECOME PREGNANT, HOW DO I DO IT SAFELY?

• ANSWER: YES; PREFERABLY WITH A DOCTOR’S GUIDANCE– Three issues:

• Reducing horizontal transmission – b/w partners • Reducing vertical transmission – mother -> child*• Keeping mother and baby healthy

*Details in DHHS guidelines – http://aidsinfo.nih.gov/guidelines/

Canadian HIV Fertility Program

VISION:

To champion a collaborative

program

that guides and assists

people living with HIV in

Canada

with their fertility desires

and pregnancy planning

in a holistic, ethical,

supportive and

medically sound manner

The Women and HIV Research Program

Canadian HIV Fertility Program Diagram

• One of Program’s Goal: to have the discussion of pregnancy, reproduction, pre-conception planning as part of routine HIV care– Between all HCP & HIV-positive patients

• Why: many reasons– Allow for discussion of contraception, sexual health,

harm & transmission reduction, criminalization– We want pregnancies of HIV-positive women to be

planned in order to improve maternal & infant health, and reduce vertical and horizontal transmission

The Women and HIV Research Program

Canadian HIV Pregnancy Planning Guidelines

The Women and HIV Research Program

Issues Related to Pregnancy Planning and HIV

Fertility and HIV:

Four main issues need to be considered:1) Prevention of Vertical Transmission

• Viral transmission from the mother to the child2) Healthy pre-conception3) Prevention of Horizontal Transmission

• Viral transmission between partners or interacting individuals

4) Fertility issues• If the individual or couple has infertility

Picture from: http://www.tthhivclinic.com/overview_home.htm 1Perinatal HIV Guidelines Working Group 2007 http://aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf.

The Women and HIV Research Program

21%

8%4%

1%0

10

20

30%

Tra

ns

mis

sio

n

None AZT Alone

Less PotentCombo

PotentCombo (PI)

Women & Infants Transmission Study, 1990-1999Cooper E et al. JAIDS 2002;29:484-94

More Potent Antiretroviral Regimens are Associated with Lower Perinatal Transmission

The Women and HIV Research Program

HIV Pregnancy Guidelines

Guidelines Updated – 2014:• Centers for Disease Control and Prevention. U.S.

Public Health Service Task Force recommendations

for use of antiretroviral drugs in pregnant HIV-1-

infected women for maternal health and interventions

to reduce perinatal HIV-1 transmission in the United

States.

– Including use of ARVs & C/S and not breastfeeding

– Up to date guidelines:

http://aidsinfo.nih.gov/guidelines/

The Women and HIV Research Program

General Principles for Pregnancy Planning

• Taking Folic Acid: 1 mg a day for 1-3 months before and during 1st trimester of pregnancy

• Not smoking and drinking • Maintaining a balanced diet• Terminating the use of recreational drugs

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The Women and HIV Research Program

Antiretroviral drugs and fertility• Preference is to have HIV+ person on appr. Drugs

before pregnancy– Any ARVs except Efavirenz, D4T, ddI, ddC in women – i.e. 3 ARVs – 2 NRTIs (e.g. Combivir, Kivexa, Truvada) +

boosted PI or NNRTI or Integrase Inhibitor– For >3-6 months with viral load <40 copies/mL– Future mother and father should not have received HCV

treatment for 6 months before conception

• Exceptions:– Women - long-term or slow progressor who doesn't need

ARVs for her own health (i.e. CD4 > 500 cells/uL), can wait until 12-14 weeks gestation

The Women and HIV Research Program

Prevention of Horizontal Transmission

• Different clinical scenarios:

1. HIV+ woman with HIV- man (serodiscordant) or who is single or in same sex relationship

2. HIV+ man and HIV- woman (serodiscordant)

3. HIV+ man and woman (seroconcordant)

4. HIV+ man who is single or in same sex relationship or couple seeking egg donation or surrogate mother

• Different clinical scenarios have different risk of and require different strategies to prevent horizontal transmission

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The Women and HIV Research Program

For all scenarios

• Review all different options for insemination/conception attempt & continuum of risk including:– Unprotected intercourse (on ART, full viral suppression)– Unprotected intercourse with timed ovulation (on

ART, full viral suppression)– Home insemination (i.e. turkey baster method)– Intrauterine insemination (IUI) (in fertility clinic)– Sperm washing followed by IUI– Other: IVF, ICSI, gestational carrier, adoption

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The Women and HIV Research Program

Fertility Issues• Possibly increased in HIV; Age issue

• Fertility investigations

• Options for fertility treatment:– Ovulation stimulating drugs– Intrauterine Insemination (IUI)– In Vitro Fertilization (IVF)– Intracytoplasmic Sperm Injection (ICSI)

Questions?

During Pregnancy• Centers for Disease Control and

Prevention. U.S. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. – July 31, 2012 & March 31, 2014

• http://aidsinfo.nih.gov/guidelines/

Summary of what is new in DHHS Guidelines – July 2012

• Included piece on Pre-concepetion • Atazanavir/ritonavir now a preferred

drug in pregnancy along with Kaletra– Use in combination with Combivir

(preferred), Kivexa (if HLA B-5701 negative) or Truvada (alternative)

• Treating with ARVs earlier in pregnancy – i.e. no later than week 12 of gestation– Some start ARVs right away when

pregnant, even 4 or 6 weeks gestation

Summary of what is new in DHHS Guidelines – July 2012

• If an HIV+ woman becomes pregnant on ARVs – do not change ARVs if safe– More harm from changing; poss. nausea

with new regimen; risk of stopping– Even Sustiva (Atripla) can continue; only

said not to use in first 6 weeks gestation• If woman presents late in pregnancy

(i.e. 3rd trimester) or with very high viral load, add Raltegravir to regimen– Commonly use Truvada with Kaletra +

Raltegravir

• Changes to use of intravenous (IV) zidovudine during labor if VL < 400c/mL

Summary of what is new in DHHS Guidelines – March 2014

• Kivexa and Truvada added as preferred

NRTI to Combivir• Atazanavir/ritonavir and Kaletra still

preferred • Efavirenz now preferred NNRTI after 8

weeks gestation• Raltegravir – alternative

The Women and HIV Research Program

Scenario #1

• 27 year old HIV+ woman with HIV- male partner

– She is on Atripla with VL < 50 copies/mL & CD4 count 480 cells/uL & they want to get pregnant

– How do you counsel them?

The Women and HIV Research Program

Scenario #1 – HIV+ woman with HIV- male partner

• Counsel her to switch from Atripla since before pregnancy; start folic acid 1-5 mg per day

• Insemination options– Unprotected sex with timed ovulation– Home insemination with syringe– Assisted insemination – in fertility clinic (intra-uterine

insemination)

• How to do home insemination– Time ovulation (1 day per month; 14 days before

next FDMP) or insert semen on day 11, 13, 15, and 17 of cycle

– Use a turkey baster or syringe

The Women and HIV Research Program

Scenario #2

• Couple: HIV+ man and woman in their late twenties

– Both on ARVs (he is on Atripla and she is on Truvada + Isentress ) with VL < 50 copies/mL & good CD4 count values

– Referred for consideration of and assistance with pregnancy planning and related issues

The Women and HIV Research Program

Scenario #2 – HIV+ man and woman• She can stay on her ARVs & him as well; she

is to start folic acid

• Insemination options– Unprotected sex on ART with timed

ovulation – HPTN052 STUDY– Sperm washing in fertility clinic followed by IUI

• Issues– In this scenario – it is recommended that

both individuals be taking ARVs with VL < 50 copies/mL

– Risk of SUPERINFECTION because of discordance of virus in genital secretions

The Women and HIV Research Program

HPTN 052 StudyRandomized Control Trial

Compare early versus delayed (CD4 < 250) ART for HIV-1 positive patients having 350-550 CD4 per mm3 and in stable sexual relationship with uninfected partner –outcome:• Transmission to uninfected partner (linked)

893 couples in Early Therapy Arm; 882 couples in Delayed Therapy Arm

28 HIV-transmissions were linked: 27 in Delayed Arm; 1 in Early Arm (occurred at 3 months post-ARVs) (0.1 per 100 person-years) [HR 0.04 (CI 0.01-0.27); p<0.001] = 96% reduction of HIV transmission with ART

The Women and HIV Research Program

Sharing information: PamphletsAvailable in French & English at www.catie.ca

The Women and HIV Research Program

Sharing information: Workshops

Canadian HIV Women’s Sexual and Reproductive

Health Cohort Study

Study Overview: What is CHIWOS?

Current Study Provinces

Potential Future Study Provinces

• CHIWOS: the Canadian HIV WOmen’s Sexual and Reproductive Health Cohort Study

• Cohort of about 1400 women living with HIV in BC, ON, QC• 5 year study: April 1st 2011 to March 31st 2016• Anchored in Community-based Research principles• Guided by Critical Feminist, Anti-Oppression and Social Justice

frameworks

CHIWOS: Study Goals

• Among HIV-positive women

–To assess barriers to and facilitators of women-specific HIV/AIDS services use

–To assess the impact of such patterns of use on sexual, reproductive, mental and women’s health outcomes

CHIWOS Study Design

• Recruitment at clinics, ASOs, PRAs, and aims to enrol 350 women from QC & BC and 700 from ON (esp. hard to reach women)

• The survey instrument: online; at baseline & then every 18 months

• Using COMMUNITY-BASED RESEARCH PRINCIPLES

• Surveys done with PRAs – 21 in ON, 8 in BC & 8 in QC• Regional sampling goals in each province • Prioritizing harder-to-reach and marginalized

populations in order to learn more about their experiences, and to better meet their needs

Sampling Targets for Ontario

Population Target Actual Required

Younger women 70 38 32Older women 70 77 NoneTrans women 35 8 27LGBQQ2S Women 70 63 7

Aboriginal women 70 41 29ACB women 70 157 None‘Other' women of colour 70 46 24

Not accessing care 70 27 43History of IDU 70 60 10History of sex work 70 34 36

Region Target Actual Required Percentage Complete

Toronto 288 202 86 70%Ottawa 87 65 22 75%Central West 80 41 39 51%South West 70 17 53 24%Central East and Eastern 70 19 51 27%Northern 70 16 54 23%

Regional Targets

Priority Population Targets

Indicates <60% of target met

The Women and HIV Research Program

This is an Issue of Sexual and Reproductive Rights

“All couples and individuals have the right to decide freely and responsibly the number and spacing of their children and to have

access to the information, education and means to do so.”

World Health Organization, UN Population Fund, Joint United Nations Programme on HIV/AIDS (UNAIDS), and International Planned Parenthood Federation. Sexual and reproductive health and HIV/AIDS: A framework for priority linkages, 2005. Available at http://www.who.int/reproductive-health/stis/docs/framework_priority_linkages.pdf .

“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.

For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”

The Women and HIV Research Program

Acknowledgements

I would like to thank the Peterborough AIDS Research Network & the AIDS Committee of Durham Region for inviting me to speak and to be partners in these important knowledge

exchange activities

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Thank You!Our Team

Women and HIV Research Program Staff

Canadian HIV Fertility Program Investigators, Staff & StudentsCHPPG Development Team

Feedback and questions?

Thank you!