William Short MD, MPH Assistant Professor of Medicine, Division of Infectious Diseases Jefferson Medical College of Thomas Jefferson University [email protected].

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

amfAR, n=4831 US adultsemail survey (2008)

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.

How can preconception care be integrated into the HIV primary care setting?

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

Integrating preconception and HIV care

Guide to preconception counseling for the HIV care provider

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]