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Welcome! The Webinar will being in just a few minutes. Please remember to turn on your computer speakers and adjust speaker volume. Reproductive Health and HIV: Preconception Care, Family planning & Safer conception

This teleconference is made possible by the Cooperative Agreement #5U65PS 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.

Webinar schedule Session 1: Preconception Care in the Setting of HIV Infection Session 2: Contraceptive care for women/couples living with HIV infection Session 3: Safer conception for HIV-discordant couples

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Materials and Evaluation
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Preconception care in the setting of HIV infection
William Short MD, MPH Assistant Professor of Medicine, Division of Infectious Diseases Jefferson Medical College of Thomas Jefferson University

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

Role Play Case study Gloria is a 32 year old HIV+ AA female
HIV acquired from a previous boyfriend No significant medical history/on no medication CD4 380 and viral load is 24,000 She is returning for her 2nd visit to discuss ART Role Play

amfAR, n=4831 US adults email survey (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 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 Studies of fertility desires and intentions have shown that many women living with HIV want to have children. In a 1998 study, interviews were conducted with 1, 421 HIV-infected adults who were part of the HIV Cost and Services Utilization Study, a nationally representative probability sample of 2,864 HIV-infected adults who were receiving medical care within the contiguous United States in early Results: Overall, 28-29% of HIV-infected men and women receiving medical care in the United States desire children in the future. Among those desiring children 69% of women and 59% of men actually expect to have one or more children in the future. Chen JL et al. Fertility Desires and Intentions of HIV-Positive Men and Women. Family Planning Perspectives, 33(4) July/August In a more recent survey (published in 2011) of 450 HIV-infected women in the United Kingdom, 75% reported that they wanted more children 11% stated that the HIV diagnosis made them want children sooner, and 41% of women who initially reported no desire to have children changed their minds following advances in HIV care S. Cliffe, C. L. Townsend, M. Cortina-Borja et al., Fertility intentions of HIV-infected women in the United Kingdom, AIDS Care, vol. 23, no. 9, pp , 2011.

Fertility desires and intentions
Factors Associated with fertility desires 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 Factors that have been associated with fertility desires and intentions reflect issues related to personal health, ARV therapy, HIV transmission and social factors. B. Nattabi, J. Li, S. C. Thompson et al., A systematic review of factors influencing fertility desires and intentions among people living with HIV/AIDS: implications for policy and service delivery, AIDS and Behavior, vol. 13, no. 5, pp , 2009. Findings from the Women Living Positive survey illustrate the perceived dichotomy between personal and societal perspectives on childbearing among women with HIV. Although a majority (61%) of the 700 respondents believed that with appropriate medical care they could safely have children, 59% believed that society strongly urges them not to have children. K.E. Squires, S. L. Hodder, J. Feinberg et al., Health needs of HIV infected women in the United States: Insights from the women living positive survey. AIDS Patient Care and STDS, vol. 25, no. 5. pp279-85, 2011. An exploratory survey with 74 HIV positive women found that those with higher levels of personalized stigma and negative self-image reported increased desire for children as a way of concealing their HIV positive status and improving feelings of self-worth. However, some women who had disclosed their HIV status reported they were less likely to become pregnant in order to avoid negative judgments about the risk of transmitting HIV to their child. S. M. Craft, R. O. Delaney, D. T. Bautista et al., Pregnancy decisions among women with HIV, AIDS and Behavior, vol. 11, no. 6, pp , 2007.

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. Underuse of hormonal contraception and barrier methods leaves women with HIV at risk for unintended pregnancy, HIV transmission and other acquisition of other sexually transmitted infections (STIs). In the WIHS cohort analysis of pregnancies between 1994 and 2002, 77% of pregnancies occurred despite use of contraception , implying that the pregnancies were unintended and highlighting the importance of adequate and accurate counseling about use of effective birth control. Across almost 27,000 visits by 2784 HIV-infected and high-risk HIV-uninfected women in the WIHS cohort from , barrier methods were used at <40% of visits, hormonal methods at in fewer than 10%, and no contraception in over 30% of visits. HIV status was not correlated with barrier use but hormonal contraception was less likely among women with HIV (OR 0.73, 95% CI , P=0.002). Massad LS et al. Contraceptive Use among U.S. Women with HIV J Women's Health Jun;16(5):657-6 Massad et al. (2007) J Women’s Health

Estimated # of births to women with HIV
There is evidence that these or other factors are indeed resulting in an increase in births to women living with HIV. This estimate for the number of HIV-infected infants born in the United States is based on the new estimated annual number of HIV-infected women delivering infants in the U.S. This data comes from Suzanne Whitmore of CDC’s HIV Incidence and Case Surveillance Branch. Beginning with the estimate of women per year made earlier in this decade, we see an increase of more than 30% in the number of HIV-infected women delivering in the U.S. Whitmore S, Zhang X, Taylor A. Estimated number of births to HIV+ women in the US, In: Program and abstracts of the 16th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2009; Montréal, Canada. Abstract 924.poster available at 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 (pre-HAART era) and (HAART era) in HIV+ and HIV- women 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 Sharma et al. found that the live birth rates were higher in all age categories in the post-HAART era but the largest difference (a 306% increase) was seen in women >35 years old. The birth rate was higher in HAART era within each category of CD4 count, so it’s not just the healthiest women becoming pregnant. Women with history of IDU were the only group in both HIV+ and HIV- women who experienced a decline in birth rates. Sharma, et al. Live birth patterns among human immunodeficiency virus-infected women before and after the availability of highly active antiretroviral therapy. AJOG 2007;196:541e1-6

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 enough CDC. MMWR 2006;55:1-23 Scientific evidence indicates that improving a woman’s health before pregnancy will improve pregnancy outcomes. However, for many years our efforts have focused primarily on prenatal care and on caring for infants after birth. (This pattern is also typical in the context of women living with HIV infection.) Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. Atrash H et al. Where is the “W”oman in MCH?. American Journal of Obstetrics and Gynecology, Supplement to Dec 2008; S259.

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 In addition to the general components that are appropriate for all women of reproductive age, HIV-infected women require additional preconception counseling and interventions Access to preconception care (PCC) aimed at promoting pregnancy planning, use of contraception to reduce unintended pregnancies, and safer conception is needed to optimize health outcomes for women living with HIV and to strengthen prevention efforts for at risk partners and children. The American College of Obstetricians and Gynecologists (ACOG) and the Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission and other national organizations recommend offering all HIV-infected women of childbearing age comprehensive family planning and the opportunity to receive preconception counseling and care as a component of routine primary medical care. American College of Obstetricians and Gynecologists (ACOG), Gynecological care for women with human immunodeficiency virus, Practice Bulletin, Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission, 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, , 2011

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

This slide presents trends from 1985 through 2009 in the estimated numbers of AIDS diagnoses among persons who were perinatally infected in the 50 states, the District of Columbia, and the U.S. dependent areas. The blue line shows the annual numbers of perinatally infected children who were diagnosed with AIDS when they were less than 13 years of age; the pink line shows the annual numbers of persons who were infected with HIV perinatally and were diagnosed with AIDS at the age of 13 or older. As the pink line shows, the number of perinatally infected persons aging to adolescence and adulthood before being diagnosed with AIDS is increasing gradually. This may be an indication of successful treatment and care. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.

Unintended pregnancy 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% unplanned 49-52% HIV status known Italy 334 HIV+ on ARV 57.6% unplanned Italy: 334 women on ART at time of conception- 57.6% unplanned pregnancies (Floridia et al. Antivir Ther 2006;11:941) Koenig et al. AJOG 2007: HIV+ pregnant US adolescents (n=1090): HIV status known prior to pregnancy in 50%; 83.3% pregnancies unplanned -43% of these-no contraception; HIV/AIDS Reporting System (HARS, ) and the Perinatal Guidelines Evaluation Project (PGEP, ). Finer and Henshaw (2006) Perspec Sex Repro Health; Massad (2004) AIDS Koenig (2007) AJOG ; Floridia (2006) Antivir Ther

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 optimized We can harness the scientific and behavioral interventions that have brought us to this exciting crossroads and support HIV-affected men and women realize their sexual and reproductive health desires. Squires 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 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

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 Photo: A counseling guide for providers with suggested scripts for discussing fertility desires and preconception care with women of reproductive age living with HIV. In addition to those outlined by the CDC Preconception Care Work Group, the following components of preconception counseling and care are specifically recommended for HIV-infected women. Health care providers should educate and counsel women about risk factors for perinatal transmission of HIV, strategies to reduce those risks, potential effects of HIV or treatment on pregnancy course and outcomes, and the recommendation that HIV-infected women in the United States not breastfeed because of the risk of transmission of HIV and the availability of safe and sustainable infant feeding alternatives. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission, 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, , 2011.

Address alcohol, drugs and/or tobacco use Recommend avoidance of OTCs Consider delaying pregnancy until health is optimized Preconception care is a series of interventions that are focused on identifying and modifying risks to a woman’s health and pregnancy outcome through prevention and management. Benefits of PCC in identifying and modifying risks to maternal health and pregnancy outcomes and in preventing unwanted pregnancies are well documented.Appropriate preconception health improves pregnancy outcomes. Counsel on prevention of infection with toxoplasmosis, CMV and parvovirus B19 Environmental toxins such as cigarette smoke, alcohol and street drugs, and chemicals such as solvents and pesticides should be avoided Optimize disease control (diabetes, hypertension) Medications for hypertension, epilepsy, thromboembolism, depression and anxiety should be reviewed and changed, if necessary, before the patient becomes pregnant. Counseling about exercise, obesity, nutritional deficiencies and the overuse of vitamins A and D is beneficial. ACOG (2008). Preconception Care: A guide for optimizing pregnancy outcomes Brundage S et al., Preconception Health Care. American Family Physician, 65(12) , June 2002 ACOG (2008). Preconception Care: A guide for optimizing pregnancy outcomes

Optimize preconception health
Screen for: Syphilis Refer for: Genetic screening, based on history Contraception, as needed, to delay pregnancy while health issues are addressed Provide: Folic acid 400 mcg daily Immunizations, as needed, for: hepatitis B rubella varicella When started at least one month before conception, folic acid supplements can prevent neural tube defects. Targeted genetic screening and counseling should be offered on the basis of age, ethnic background or family history Immunizations against hepatitis B, rubella and varicella should be completed, if needed.

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. Any HIV-infected pregnant woman who meets standard criteria for initiation of ART as per ARV guidelines in nonpregnant adults should receive potent combination ART, generally consisting of NRTIs plus a non-nucleoside reverse transcriptase inhibitor (NNRTI) or protease inhibitor (PI), with continuation of therapy postpartum. Treatment should be started as soon as possible—including in the first trimester—for women who require immediate initiation of therapy for their own health because the potential benefit of treatment for the mother outweighs potential risks to the fetus. The regimen generally should be chosen from among those shown to be effective in nonpregnant adults, taking into account what is known about use of the drugs during pregnancy and risk of teratogenicity (see General Principles Regarding Use of Antiretroviral Drugs during Pregnancy). When prescribing ART to women of childbearing age consider the regimen’s effectiveness for treatment of HIV, an individual’s hepatitis B disease status, the drugs’ potential for teratogenicity should pregnancy occur, and possible adverse outcomes for mother and fetus. Use the preconception period in women who are contemplating pregnancy to adjust ARV regimens to exclude efavirenz or other drugs with teratogenic potential. For women who are on ART for their own health and who want to get pregnant, make a primary treatment goal the attainment of a stable, maximally suppressed maternal viral load prior to conception to decrease the risk of mother-to-child transmission. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission, 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, , 2011.

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

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 Guidelines: 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

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

An informational brochure for clients on preconception health and the importance of preconception care An informational brochure for patients that defines preconception health and explains the importance of preconception care for women living with HIV.

Photo: Client questionnaire and provider checklist
This is a two–part tool to support preconception care. The front side is a patient questionnaire that explores fertility desires and basic reproductive history. The back side is a provider checklist to provide guidance on providing basic contraceptive and preconception counseling and care during a primary care visit.

An algorithm for HIV providers showing the components of preconception care for women living with HIV who are of reproductive age.

Guide to preconception counseling for the HIV care provider A counseling guide for providers with suggested scripts for discussing fertility desires and preconception care with women of reproductive age living with HIV.

Questions and Comments*
*Type in the chat box and then click “Enter”

Contraceptive Care for Women with HIV Infection and their Partners
Kimberly McClellan, MSN, WHNP-BC, CRNP Director Women's Health AIDS Care Group, Chester PA

Objectives Describe considerations for selecting appropriate contraceptive and compare options for women living with HIV Explain specific consideration related to hormonal contraception and antiretroviral treatment Identify issue related to hormonal contraception and HIV progression, transmission or acquisition

Role Play Case study One year later:
Gloria initiated ATV/r + TDF/FTC combination therapy and has achieved viral suppression with CD4 count of 500 She is here for a routine visit and is doing well Role Play

Benefits of Contraception for HIV-Positive Women
Prevents unintended pregnancy Half of all pregnancies in U.S. are unintended Allows women to plan a pregnancy that Is well timed Occurs in optimal health Minimizes risks for perinatal transmission Centers for Disease Control and Prevention. (2010, April 30). Unintended pregnancy prevention: Home. Retrieved from Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. (2011, September 14). 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. Retrieved from

Special Considerations Regarding HIV and Contraception
Potential drug interaction with antiretrovirals (ARVs) Possible effects on HIV transmission Possible effects on HIV acquisition Possible effects on HIV progression

Typical Effectiveness of Contraception
HIV-positive women generally have the same options as uninfected women Talking Points One of the most important strategies to decrease the proportion of unintended pregnancies is the use of effective family planning methods. This chart shows the relative typical effectiveness of various family planning methods – typical effectiveness refers to how effective the different methods are at preventing pregnancy during actual use, including inconsistent or incorrect use. At the top you will find male and female sterilization, along with long acting reversible contraceptives or LARCS, which include intrauterine devices or IUDs and contraceptive implants. More commonly used, and less effective methods, are listed below such as injectables and oral contraceptives shown in the second row from the top and condoms shown in the third row from the top. References Adapted from: WHO. Family Planning: A Global Handbook

US Medical Eligibility Criteria for Contraceptive Use

US Medical Eligibility Criteria: Categories

Oral contraceptives Same medical criteria as for HIV-uninfected women if woman is NOT on ART Drug-drug interactions are possible between ARVs and hormonal contraceptives (HCs) HCs are metabolized by same pathways and cytochrome P450 enzymes as many PIs and NNRTIs These interactions can cause changes in the efficacy of the ARV or contraception ACOG (2010), Gynecologic care for women with human immunodeficiency virus. Practice Bulletin #117.

Hormonal Contraception: Alternate Delivery Methods
Combined Patch is a thin plastic square worn on body Releases estrogen and progestin through the skin Works by preventing ovulation Efficacy Limited research suggests may be more effective than COCs Decreased efficacy in women over 90 kg

Limited research suggests health risks and benefits are similar to COCs Side Effects Skin irritation or rash where patch is applied Changes in bleeding pattern Headaches Nausea Vomiting Breast tenderness Abdominal pain World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. (2007) Family planning: A global handbook for providers. Baltimore and Geneva: CCP and WHO.

Combined Vaginal Ring is placed into the vagina Releases estrogen and progestin Works by preventing ovulation Efficacy Limited research suggests may be more effective at preventing pregnancy than COCs World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. (2007) Family planning: A global handbook for providers. Baltimore and Geneva: CCP and WHO.

Alternative Delivery Methods
Limited research suggests risks and benefits similar to COCs Side effects Changes in bleeding pattern Headaches Nausea Breast tenderness Vaginitis Leukorrhea/increase in Lactobacillus World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. (2007) Family planning: A global handbook for providers. Baltimore and Geneva: CCP and WHO.

Alternate Delivery Methods
These delivery methods also vulnerable to drug interactions One small study found significant interaction between the estrogen and progestin hormones of the patch and lopinavir/ritonavir More research needed on these delivery methods Vogler, M.A., Patterson, K. et al. (2010, December 1). Contraceptive efficacy of oral and transdermal hormones when co-administered with protease inhibitors in HIV-1 infected women: Pharmacokinetic results of ACTG trial A5188. J Acquir Immune Defic Syndr, 55(4),

DMPA Injectable (IM,SQ) progestin only contraception
Given every 3 months Works by preventing ovulation Efficacy 97% effective as commonly used Over 99% effective when used as directed (3 pregnancies per women) World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. (2007) Family planning: A global handbook for providers. Baltimore and Geneva: CCP and WHO.

Contraceptive Implants
Thin rods or tubes containing a progestin hormone. Provide effective contraception for at least 3 yrs. Suppresses ovulation and changes cervical mucus. Menstrual irregularities in most users.

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

Medical Eligibility Criteria for IUD*
LNG-IUD Cu-IUD Initiation Continuation High Risk for HIV 2 HIV Infection AIDS 3 Clinically Well on ARV Therapy *Adapted from: U.S. medical eligibility criteria for contraceptive use. Centers for Disease Control and Prevention. (2010, May 28). U.S. medical eligibility criteria for contraceptive use, 2010: Adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th edition. MMWR Early Release, 59. Category 2: A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. Category 3: A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.

IUD and HIV Considerations
No higher risk in HIV-positive women over uninfected women for Complications Infections IUD use not associated with increased risk for transmission to sex partners Women with IUD in place who develop AIDS should be monitored for pelvic infection Centers for Disease Control and Prevention. (2010, May 28). U.S. medical eligibility criteria for contraceptive use, 2010: Adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th edition. MMWR Early Release, 59.

Hormonal Contraception and NNRTI Interaction Table
Efavirenz (EFV) No effect on oral ethinyl estradiol Decreased active metabolites of norgestimate (levonorgestrel AUC ↓ 83%; norelgestromin ↓64%) Implant: ↓ etonogestrel Levonorgestrel AUC ↓58% A reliable method of barrier contraception must be used in addition to HC due to decreases in progestin levels. A reliable method of barrier contraception must be used due to reports of contraceptive failure. Effectiveness of emergency contraception may be diminished Etravirine (ETR) Ethinyl estradiol AUC ↑22% Norethindrone: no significant effect No dosage adjustment necessary Nevirapine (NVP) Ethinyl estradiol AUC ↓20% Norethindrone AUC ↓19% DMPA: no significant change Use alternative or additional methods No dosage adjustment needed Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. (2011, September 14). 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. Retrieved from

Hormonal Contraception and Ritonavir-boosted PI Table
Atazanavir/ritonavir (ATV/r) ↓ Ethinyl estradiol ↑ Norgestimate Oral contraceptive should contain at least 35 mcg of ethinyl estradiol. OCs containing progestins other than norethindrone or norgestimate have not been studied. Darunavir/ritonavir (DRV/r) Ethinyl estradiol ↓44% Norethindrone AUC ↓14% Use alternative or additional method. Fosamprenavir/ritonavir (FPV/r) Ethinyl estradiol AUC ↓37% Norethindrone AUC ↓34% Lopinavir/ritonavir (LPV/r) Ethinyl estradiol AUC ↓42% Norethindrone AUC ↓17% Saquinavir/ritonavir (SQV/r) ↓Ethinyl estradiol Tipranavir/ritonavir (TPV/r) Ethinyl estradiol AUC ↓48% Norethindrone: no significant change Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. (2011, September 14). 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. Retrieved from

Hormonal Contraception and PIs without Ritonavir Table
Atazanavir (ATV) Ethinyl estradiol AUC ↑48% Norethindrone AUC ↑110% Oral contraceptive should contain no more than 30 mcg of ethinyl estradiol or use alternative method. OCs containing less than 25 mcg of ethinyl estradiol or progestins other than norethindrone or norgestimate have not been studied. Fosamprenavir (FPV) With APV: ↑Ethinyl estradiol and ↑norethindrone; ↓APV 20% Use alternative method. Indinavir (IDV) Ethinyl estradiol AUC ↑25% Norethindrone AUC ↑26% No dose adjustment. Nelfinavir Ethinyl estradiol AUC ↓47% Norethindrone ↓18% Use alternative or additional method. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. (2011, September 14). 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. Retrieved from Adapted from: 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.

Hormonal Contraception and CCR5 antagonist/integrase inhibitor table
Maraviroc (MVC) No significant effect on ethinyl estradiol of levonorgestrel Safe to use in combination Integrase inhibitor Raltegravir No significant drug effect No dose adjustment necessary Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. (2011, September 14). 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. Retrieved from Adapted from: 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.

Condoms Efficacy Pregnancy prevention as commonly used
Male condom 85% Female condom 79% Pregnancy prevention when used correctly and consistently Male condom 98% Female condom 95% Male condom is 80-95% effective at preventing HIV transmission when used correctly and consistently World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. (2007) Family planning: A global handbook for providers. Baltimore and Geneva: CCP and WHO.

Dual Contraceptive Use
Condom use should be encouraged for women To prevent HIV/STI acquisition Condom use should be encouraged in HIV-positive women To prevent HIV transmission Prevent STI acquisition As an adjuvant to contraceptives Condoms alone have a failure rate of 15%-21% at preventing pregnancy American College of Obstetricians and Gynecologists (ACOG). (2010, December). Gynecologic care for women with human immunodeficiency virus. Obstetrics and Gynecology, 116(6), World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), INFO Project. (2007) Family planning: A global handbook for providers. Baltimore and Geneva: CCP and WHO.

Spermicides: Not recommended
Spermicides are not recommended by CDC Disrupt cervical mucosa Potentially increase viral shedding Increase transmission of HIV to uninfected partners Diaphragms and cervical caps are not encouraged by the CDC due to concerns about their use with spermicides Centers for Disease Control and Prevention. (2010, May 28). U.S. medical eligibility criteria for contraceptive use, 2010: Adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th edition. MMWR Early Release, 59. World Health Organization. (2009). Medical eligibility criteria for contraceptive use fourth edition, Retrieved from

Female and Male Sterilization
Contraceptive sterilization is the most widely used method of family planning Clients should be advised that sterilization should be considered permanent Male-vasectomy: Cutting/occluding both vas deferens 1st yr failure rate-0%-0.5% Female-sterilization Transabdominal Transcervical Tubal sterilization Occlusion method

Hormonal Contraception and HIV Acquisition: WHO Technical Statement
Most studies found no statistically significant association between oral contraception and HIV acquisition Evidence on injectable HC varied with some studies showing increases between 48% to 100% and other studies reporting no association Due to inconsistent data and limitations of the studies performed WHO rated the current evidence as low World Health Organization. (2012, February 16). Hormonal contraception and HIV: Technical statement. Retrieved from

HIV Transmission and Hormonal Contraception: WHO Technical Statement
Recent observational study found a 2-3 increase in HIV transmission in women using injectables over oral contraception Findings from studies assessing HC and genital HIV shedding are not consistent Studies assessing HC and viral load generally showed no negative effect WHO rates the evidence for HIV transmission and injectable use as low and HIV transmission and oral contraception as very low World Health Organization. (2012, February 16). Hormonal contraception and HIV: Technical statement. Retrieved from

HIV Disease Progression and Hormonal Contraception: WHO Technical Statement
None of the 10 observational studies conducted found a significant association between hormonal contraception and HIV progression One randomized controlled trial found an increased risk of progression for HC users compared to copper IUD users Due to flaws in this study --- high rates of method switching and loss to follow-up --- the evidence for HC and HIV progression is rated as low World Health Organization. (2012, February 16). Hormonal contraception and HIV: Technical statement. Retrieved from

WHO Recommendations No restriction on the use of any hormonal contraceptive method for HIV-positive women or women at high risk for HIV infection Critical importance must be placed on the consistent and correct use of condoms for the prevention of HIV acquisition or transmission Most concern is focused on the evidence of HIV acquisition and DMPA because a causal relationship is neither established nor ruled out Voluntary use of contraception by HIV positive women who wish to prevent pregnancy continues to be an important PMTCT strategy World Health Organization. (2012, February 16). Hormonal contraception and HIV: Technical statement. Retrieved from

Safer Conception for Sero-Discordant Couples
Judy Levison, MD, MPH Associate Professor, Departments of Obstetrics and Gynecology and Family and Community Medicine Baylor College of Medicine Houston, Texas

Objectives Describe two methods of conception for an HIV+ woman and an HIV- man List three methods of conception for an HIV+ man and an HIV- woman

The Serodiscordant Couple

HIV discordance in couples
Population based sample of HIV infected persons in care 58% of men and 70% of women had a primary partner 50% of couples were in serodiscordant relationships 20% were in relationships with partners whose HIV status was unknown Family Planning Perspectives, 33 (4); , 2001 Estimated 140,000 serodiscordant heterosexual couples in the U.S., about half of whom want children Am Journal of Obst and Gyn, 204(6), 488e1-8, 2011 Although recent data are not available, a study of a population based sample of HIV-infected persons in care in 1996 found that 58% of men and 70% of women had a primary partner or spouse; approximately 50% of couples were in serodiscordant relationships and almost 20% were in relationships with partners whose HIV status was unknown. J. L. Chen, K. A. Philips, D. E. Kanouse et al., Fertility desires and intentions of HIV-positive men and women, Family Planning Perspectives, vol. 33, no. 4, pp , 165, 2001. Extrapolating from this information and incorporating 2006 data about number and demographics of heterosexual adults living with HIV in the U.S., it has been estimated there are an approximately 140,000 HIV-heterosexual serodiscordant couples in the US, about half of whom want more children. This has significant implications in providing accurate information on achieving safe conception in the presence of HIV discordance. M. A. Lampe, D. K. Smith, G. J. Anderson et al., Achieving safe conception in HIV-discordant couples: the potential role of oral pre-exposure prophylaxis (PrEP) in the United States, American Journal of Obstetrics and Gynecology, vol. 204, no. 6, pp. 488 e1-8, 2011. A number of studies have suggested that HIV has an adverse effect on fertility in both symptomatic and asymptomatic women. This includes increased risk of infertility and pregnancy loss and higher viral loads are associated with decreased fertility. R. H. Gray, M. J. Wawer, D. Serwadda et al., Population-based study of fertility in women with HIV-1 infection in Uganda, Lancet, vol. 351, no. 9096, pp , 1998. L. M. Lee, P. M. Wortley, P. L. Fleming et al., Duration of human immunodeficiency virus infection and likelihood of giving birth in a Medicaid population in Maryland, American Journal of Epidemiology, vol. 151, no. 10, pp , 2000. R. H. Nguyen, S. J. Gange, F. Wabwire-Mangen et al., Reduced fertility among HIV-infected women associated with viral load in Rakai district, Uganda, International Journal of STD & AIDS, vol. 17, no. 12, pp , 2006 However, recent data suggest that effective ARV therapy may restore or improve fertility. As women receive effective treatment, they may become at increased risk for unintended pregnancy. F. E. Makumbi, G. Nakigozi, S. J. Reynolds et al., Associations between HIV Antiretroviral Therapy and the Prevalence and Incidence of Pregnancy in Rakai, Uganda, AIDS Research and Treatment, vol. 2011, pp , 2011. L. Myer, R. J. Carter, M. Katyal et al., Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in Sub-Saharan Africa: a cohort study, PLoS Med, vol. 7, no. 2, pp. e , 2010.

Role Play Case presentation Two years later:
Gloria continues to do well on her combination regime and maintains an undetectable viral load. At this appointment she seems anxious to discuss some big news. Role Play

The first two responses may have been appropriate before we saw the successes of the HAART era
But in 2012: 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 test kits 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

Home insemination During the 24 hours after the LH surge has occurred as documented by the ovulation predictor kit, ejaculate into a cup or into a condom without a spermicide Suction semen into a syringe Place syringe in vagina and deposit semen Remain lying down for 20 minutes Return to having protected sex with condoms

Alternatives Insemination in a doctor’s office with partner’s semen
Penile/vaginal intercourse only during the 24 hours after the LH surge and using condoms the rest of the month. Placing the woman on ARVs prior to attempted conception will further protect her partner Post or pre-exposure prophylaxis for male (PEP or PrEP)? If yes, how many doses? Baeten, J. and Celum, C. (2011) 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.

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

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 CD ) Barreiro et al. (2007) Human Reproduction, 22 (9), 2353 Cohen, M. et al. (2011). NEJM 365:

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

Preconception counseling is not being addressed
Data suggests that reproductive counseling does not often occur until after conception Recent study of 181 women: Only 31% reported a personalized discussion with their provider specific to their childbearing plans. Of those who had a personalized discussion, most were initiated by the client rather than the provider. Women living with HIV express the desire to talk about reproductive plans with their healthcare providers; however, data suggests that such counseling does not often occur until after conception [22, 34, 35]. K. E. Squires, S. L. Hodder, J. Feinberg et al., AIDS Patient Care and STDS, vol. 25, no. 5, pp , 2011. L. S. Massad, C. T. Evans, T. E. Wilson et al., Journal of Women's Health (Larchmt), vol. 16, no. 5, pp , 2007. M. A. Lampe, D. K. Smith, G. J. Anderson et al. American Journal of Obstetrics and Gynecology, vol. 204, no. 6, pp. 488 e1-8, 2011. In a recent study of 181 women, 67% reported having a general discussion about pregnancy with their HIV health provider, but only 31% of women reported a discussion that was personalized and specific to their future childbearing plans. Of those who had a personalized discussion, most were initiated by the patient rather than the provider. S. Finocchario-Kessler, J. K. Dariotis, M. D. Sweat et al., AIDS Patient Care and STDS, vol. 24, no. 5, pp , 2010. S. Finocchario-Kessler, et al., AIDS Patient Care and STDS, 24(5), , 2010

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?

Support Tools: EPIC Template
Do you know and understand your CD4 count and viral load? 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

Final notes on preconception counseling…
Contraception and pregnancy desires change over time. Just because someone did not desire pregnancy in does not tell you what he or she wants in 2013. Don’t forget to ask the men if they and their partners are planning a pregnancy. Let them know that there are preconception counseling services available.

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