1. Fertility Regulation in the Setting of HIV: What are the Controversies? Jane Hitti, MD, MPH University of Washington

2. Controversy #1 Aren’t condoms sufficient contraception for HIV-affected heterosexual couples?

3. Risk of Events Per Single Act of Unprotected Intercourse 0 10% 20% 30% 40% InfectionPregnancy Gonorrhea,Syphilis Chlamydia HIV (if co factors) Peri ovulatory 4-5 days pre ovulation During menses Risk Per Coital Act 50% Sources: Anderson (1999); Wilcox (1995) Slide from Ward Cates

4. Estimated Date at which Events would Occur from 2 Acts of Unprotected Intercourse Per Week Jan.AprilJulyOct.Dec. Syphilis Gonorrhea ChlamydiaPregnancyHIV (if cofactors) Slide from Ward Cates

5. Dual protection Unintended pregnancy Sexually transmitted infection

6. Contraceptive Failure Rates Hatcher et al, Contraceptive Technology 17 th edition, 1998 Annual Pregnancy Rate

7. Dual protection for HIV-positive women n HIV-positive women are more likely to use condoms consistently and less likely to use other methods of contraception n Reliance on condoms as a primary contraceptive method increases risk of unintended pregnancy

8. Controversy #2 Are other methods of contraception safe for HIV-infected women, particularly those on ART?

9. Safety of contraception (risk of death per 100,000 woman years) Hatcher et al, Contraceptive Technology 17 th edition, 1998

10. Controversy #3 Why do ART clinical trials and roll-out programs need to be concerned with family planning? (Can’t someone else do this?)

11. WHO Four-phase Strategy for Perinatal HIV Prevention Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIV- infected women Prevention of transmission from an HIV- infected woman to her infant Support for mother and family Phase 1Phase 2Phase 3Phase 4 Slide from Ward Cates

12. Single-Dose Nevirapine vs. Effective Contraceptive Services (1000 HIV-infected Women during 1 Year) Number of Children Slide from Ward Cates

13. Contraception to Prevent HIV Sequelae n Effective contraception for HIV-infected women who do not wish to become pregnant prevents more infants from becoming infected than single-dose NVP, and also decreases the number of future orphans n This remains the BEST KEPT SECRET in HIV prevention n We urgently need more research on optimal contraceptive approaches for HIV-infected women Cates, Sex Trans Dis 2004;31:3-7