preconception and reproductive health for women and men living with hiv 2012 ftcc meeting shannon...
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PRECONCEPTION AND REPRODUCTIVE HEALTH FOR WOMEN AND MEN LIVING WITH HIV
2012 FTCC Meeting
Shannon Weber, MSWJudy Levison, MD, MPHMary Jo Hoyt, MS, FNP
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What is preconception care it and why should we care about it?
Shannon Weber, MSW
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Disclosures
We have no financial disclosures.
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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
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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
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Estimated number of births to women living with HIV infection, 2000-2006
5500
6000
6500
7000
7500
8000
8500
9000
2000 2001 2002 2003 2004 2005 2006
High Estimate Low Estimate
Office of Inspector General (Fleming), 2002 Whitmore, et al. CROI, 2009
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amfAR email survey of US adults, n=4831 (2008)
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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
Squires et al. AIDS PATIENT CARE and STDs 2011
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Reduce stigma, normalize desires
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What are reproductive rights?
The basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.
World Health Organization
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Hey, Mom………
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Unintended pregnancy
Finer/Henshaw Perspec Sex Repro Health 2006; Massad AIDS 2004; Koenig AJOG 2007; Floridia Antivir Ther 2006
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
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Men’s sexual and reproductive health
Provides guidance to programs that plan to develop or enhance clinical services for male clients
Defines the scope of male sexual and reproductive health services and set standards for their content and design
Provides a wide range of prevention, health education and treatment issues related to male health and sexual function
http://www.cicatelli.org/titlex/downloadable/MaleGuidelines2009.pdf
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HIV heterosexual serodiscordant couples
Estimated to be 140,000 US serodiscordant couples
About half desire children Lampe, et al Am Journal Of Obst and Gyn, 204(6), 488e1-8, 2011
Increasing call volume to the National Perinatal HIV Hotline (888-448-8765) from clinicians and patients seeking safer conception options.
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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.
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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
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Preconception Care Case Studies
Judy Levison, MD, MPH
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Science: There is evidence that individual components of preconception care work:
Rubella vaccination HIV/AIDS screening Management and
control of: Diabetes Hypothyroidism PKU Obesity
Folic acid supplements Avoiding teratogens:
Smoking Alcohol Oral anticoagulants Accutane
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Role Play!
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Case 1—Roberta
30 year-old woman tested HIV+ positive during her recent pregnancy and started HIV treatment
CD4 (T-cells) have improved on treatment and her viral load is undetectable
Infant is 4 months old and HIV-uninfected Plan:
Renew medications today, check labs before she returns for a check up in 3 months.
Encourage adherence Remind to use condoms
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Case 1—Roberta…
You ask about contraception.
She previously used oral contraceptives and asks about restarting them.
How do you counsel her?
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Focus on couples where a partner is HIV-positive How do you know if your patient and his/her partner
are considering pregnancy? You have to ask! If they do NOT desire pregnancy, then ask what they
are doing for contraception Let’s review contraception and preconception
counseling for couples who are infected or affected by HIV
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Condoms
The one method that protects against STDs and provides contraception
How do your clients feel about using male condoms? Female condoms?
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Male condoms
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Female condoms
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Condoms
However, 15% failure rate in preventing pregnancy Many couples (even serodiscordant couples=one
partner HIV+ and one partner HIV-) use condoms off and on, rather than always
So, a second method is recommended
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Oral contraceptives
Same criteria as for HIV- women if woman is NOT on antiretroviral therapy (ART)
Problematic for HIV+ women on ART Ritonavir, lopinavir, nelfinavir, amprenavir, and
darunavir (PIs) and nevirapine (NNRTI) increase metabolism of ethinyl estradiol and/or norethindrone, thus lowering efficacy of OCPs
Atazanavir (PI) and efavirenz (NNRTI) increase ethinyl estradiol levels (clinical impact unknown)
ACOG (2010), Gynecologic care for women with human immunodeficiency virus. Practice Bulletin #117.
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Contraception
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Other hormonal options
Patch (Ortho Evra), vaginal ring (Nuva Ring), and transdermal implant (Implanon) Warnings are similar to OCPs regarding drug-drug
interactions However, in theory, they avoid the “first pass” effect of
liver metabolism that may occur with oral agents and should not be subject to the same limitations as OCPs
Depo-Provera: OK (concerns that DMPA might increase HIV viral shedding have not been supported)
Conference on Retroviruses and Opportunistic Infections (March 2012), Seattle.
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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
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IUDs(2)
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Permanent sterilization
Laparoscopic tubal ligation
Essure (hysteroscopically placed coils in tubes)
Postpartum tubal ligation
Vasectomy
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Laparoscopic tubal ligation
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Essure
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Postpartum tubal ligation
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Vasectomy
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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
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The Serodiscordant Couple
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Role Play!
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Case 2--Julia
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Case 2—Julia …
You ask Julia if she wants to have another child. She says, “Yes.” You ask, “When?” She says, “ Now.”
How do you counsel her?
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How do YOU feel about her wanting to get pregnant?
That is ridiculous—who will take care of your children if you die and you would risk having an HIV+ child?
I, as your health care provider, will be angry if you get pregnant.
I need to think about this. You have every right to do this. Let’s work together
to do it right.
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The first two responses may have been appropriate before we saw the successes of the HAART era
But in 2011: Perinatal transmission is <1-2% Men and women with HIV can expect to live to see their
children grow into adulthood
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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
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Serodiscordant couples
If the woman is HIV+ and the man is HIV-, discuss the options of: Ovulation predictor kits Home insemination (“turkey baster method”)
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Ovulation predictor kits
These replace the old basal body temperature charts
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When the time is right, the choices are:
Home insemination with partner’s semen
The “turkey baster” method*A needle-less syringe works fine
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Alternatives
Insemination in a doctor’s office with partner’s semen Having penile/vaginal intercourse only during the 24 hours
after the LH surge and using condoms the rest of the month—if this is the plan, then placing the woman on ARVs prior to attempted conception will further protect her partner
Post or pre-exposure prophylaxis for male? If yes, how many doses?
Baeten, J. and Celum, C. 2011. Antiretroviral pre exposure prophylaxis for HIV prevention among heterosexual
African men and women: The Partners PrEP Study. Int. AIDS Society, Rome.
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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.
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Role Play!
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Case 3—Richard
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Case 3—Richard
You ask Richard whether his fiancee has been tested for HIV He says, “Yes, and she is HIV-negative.”
You ask whether they are thinking about having children He tells you, “Yes, sooner rather than later.”
How do you counsel him?
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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
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Sperm washing
Cost is in the $1500 range Not widely available
http://aids.about.com/cs/womensresources/a/washing.htm
http://www.thebody.com/content/art911.html
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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 CD4 350-500)
Barreiro et al. (2007) Is natural conception a valid option for HIV serodiscordant couples? Human Reproduction, 22 (9), 2353
Cohen, M. et al. 2011. Prevention of HIV-1 with early antiretroviral therapy. NEJM 365: 493-505.
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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
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How can contraceptive and preconception care be integrated into routine care?
Mary Jo Hoyt, MSN
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Integrating preconception and HIV care
Simplify: Ask patients about reproductive plans Discuss the importance of planning for pregnancy Ensure contraceptive needs are met Develop a preconception plan in consultation with
experts
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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
Provide training and support
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General preconception care resources
CDC preconception care site: http://www.cdc.gov/ncbddd/preconception/
Preconception care advocacy group: http://www.beforeandbeyond.org . Includes 2011 preconception summit information Professional education materials Published articles
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Number 117, December 2010Gynecologic Care for Women With Human Immunodeficiency Virus
Guidelines
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Guidelines
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Training
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Training
FXB Center will host Preconception Care webinar. Self-study modules will also be available [Coming soon] Preconception care in the context of HIV
infection Contraceptive care for women/couples
living with HIV infection Safer conception for HIV-discordant
couples
Webinar
Self-study modules
• http://www.fxbcenter.org/• http://www.aids-etc.org
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Support tools: Patient Brochure
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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?
Do you know and understand your CD4 count and viral load?
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Support Tools: EPIC Template (2)
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
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Support tools: Client questionnaire
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Support tools: Provider Checklist
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Support tools: Counseling Guide
A counseling guide for providers with suggested scripts for discussing fertility desires and preconception care with women of reproductive are living with HIV.
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Support tools: Guidelines for Use of ARV Therapy in Pregnancy
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Clinical tools: Guidelines for Use of ARV Therapy in Pregnancy
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Expert consultation and information updates
The ReproIDHIV listserv is a forum for discussing clinical cases, finding patient referrals, sharing protocols and upcoming events, and networking with colleagues.Sponsored by:
UCSF/HRSA National HIV/AIDS Clinicians’ Consultation Center Infectious Disease Society of Obstetricians and Gynecologists UCSF Fellowship in Reproductive Infectious Disease
http://www.nccc.ucsf.edu/
To be added to the listserv contact: Shannon Weber [email protected]
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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
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Speaker contact information
Shannon Weber, MSWNational HIV/AIDS Clinicians' Consultation Center [email protected]
Judy Levison, MD, MPHBaylor College of [email protected]
Mary Jo Hoyt MSN, FNPFXB Center, UMDNJAETC National Resource [email protected]