East meets West: Management of women living with HIV

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East meets West Management of women living with
HIV
Teresa Branco Hospital Fernando Fonseca Lisbon,
Portugal

• Mariana Mardarescu
• Head of the HIV Paediatric Department in
• National Institute of Infectious Diseases
• Prof. Dr. Matei Bals
• Bucharest, Romania
• Coordinator of Compartment for Monitoring and
  Evaluation of HIV/AIDS Data in Romania

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Women for Positive Action

• A global initiative established in response to
  the need to address specific concerns of women
  living with HIV
• Women for Positive Action faculty involves
• healthcare professionals
• women living with HIV
• community representatives

Women for Positive Action is supported by a grant
from Abbott
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Contents

• Epidemiology across Europe
• HIV effects on fertility
• Infertility treatment and access to services
• Key challenges in fertility and reproduction
• Summary

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Epidemiology Western Europe
European Centre for Disease Prevention and
Control / WHO Regional Europe for Europe (2010)
HIV Surveillance in Europe 2009
5
Characteristics of newly diagnosed HIV cases in
the WHO European region (2009)
No data for West Austria, Monaco Centre
Turkey East Russia. Cases with unspecified
age and gender are excluded Persons from
countries with general epidemic are excluded
HIV/AIDS surveillance in Europe, 2009
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Epidemiology Portugal

• In June 2011 there were 40,235 PLWHA registered
  in Portugal of which 10,570 (26) were women

Instituto Nacional de Saúde Doutor Ricardo Jorge,
Departamento de Doenças Infecciosas Unidade de
Referência e Vigilância Epidemiológica
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Epidemiology Portugal

• Of 10,570 WLWH in Portugal, 1,156 were diagnosed
  during pregnancy
• Opt-out HIV testing in pregnancy

Mode of transmission
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Women living with HIV Portugal 2011

• Differences between the north and south of
  Portugal
• Women coming from countries with a generalized
  epidemic

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HIV effects on fertility
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HIV and fertility

• Evidence that HIV and HIV treatments may result
  in higher incidence of fertility disorders1,2
• Fertility treatment options are the same as
  HIV-negative couples3
• Risk reduction treatment options need to be
  considered
• Poor access of HIV-positive couples to
  reproductive assisted programs
• Limited data on IVF / ICSI success
• Early onset of menopause in HIV-positive women4

1. Chen, WJ and Walker N, Sex Transm Infect 2010
2010 Dec86 Suppl 2ii227 2. Garrabou HIV8,
Glasgow 2006, PL 9.6 3. Kalu et al, HIV Med
201011903 4. Schoenbaum et al, Clin Infect
Dis 200541151724
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Infertility in women with HIV

• Very little data on whether HIV contributes to
  infertility
• Possible contributing factors include
• age
• increased risk of cervical abnormalities
• pelvic inflammatory disease
• early menopause
• low BMI may also contribute to infertility in
  women
• alcohol and substance use
• The couple should be offered information prior to
  fertility treatment so that they can make
  informed decisions

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Infertility treatment and access to services
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Reproductive options
HIV man HIV- woman

• IUI, IVF or ICSI following sperm washing
• Natural conception (if effective viral
  suppression)
• Insemination of donor sperm at ovulation
• Pre-Exposure Prophylaxis (PrEP)?
• Adoption

HIV woman HIV- man

• Insemination of partners sperm at ovulation (if
  not on ART / detectable viral load)
• Natural conception (if effective viral
  suppression)
• Assisted reproduction in case of fertility
  disorders
• Adoption

HIV man woman

• Insemination of donor sperm or sperm washing to
  prevent superinfection
• Natural conception
• Assisted reproduction in case of fertility
  disorders

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Access to assisted reproduction options in HIV
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Reproductive discussions / counselling are an
important component of care

• Should involve a two way relationship to plan /
  prepare and make decisions
• Always try to involve partners and be culturally
  relevant
• Information, education, and discussion on

Heard I, et al. AIDS 2007Jan21 Suppl 1S7782
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Epidemiology of the HIV epidemic
Mariana Mardarescu Head of the HIV Paediatric
Department in National Institute of Infectious
Diseases Prof. Dr. Matei Bals Bucharest,
Romania Coordinator of Compartment for Monitoring
and Evaluation of HIV/AIDS Data in Romania
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Definition of geographic areas West, Centre,
East (EuroHIV)
http//ecdc.europa.eu/en/publications/Publications
/101129_SUR_HIV_2009.pdf
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Epidemiology Western Europe
European Centre for Disease Prevention and
Control / WHO Regional Europe for Europe (2010)
HIV Surveillance in Europe 2009
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HIV infections by transmission mode and year of
diagnosis in the East, 200409
Data from Estonia, Russia and Uzbekistan not
included
HIV/AIDS surveillance in Europe, 2009
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Epidemiology of HIV in Romania

• A high rate of HIV incidence in children in the
  1980s
• The peak of diagnoses was recorded at the
  beginning of the 1990s
• On 31 December 2010 16,697 cumulative cases of
  HIV/AIDS were recorded
• Total of 10,405 people living with HIV/AIDS
• During the same period, HIV incidence among the
  adult population was low, with a slight increase
  afterwards due to unprotected heterosexual
  contact
• Currently, Romania has a large number of people
  living with HIV in the 1924 age group, born
  between 19871990 (gt6000)
• a large number of PLWHA receive ARV therapy in
  relation to the total number of infected persons
  (gt7000)

Compartment for Monitoring and Evaluation of
HIV/AIDS Infection in Romania INBI
Prof.Dr.M.Bals
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HIV transmission routes in Romania, 20072010
IDU
Heterosexual
MSM
Unknown
Compartment for Monitoring and Evaluation of
HIV/AIDS Infection in Romania INBI
Prof.Dr.M.Bals
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HIV/AIDS cases among women, by age group and year
of diagnosis, 19852010
Compartment for Monitoring and Evaluation of
HIV/AIDS Infection in Romania INBI
Prof.Dr.M.Bals
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Distribution of people living with HIV in
Romania, December 2010
Age at diagnosis Total 19852010
Current age
GENDER
GENDER
M
F
F
M
70
70
65
65
65-69
65-69
60-64
60-64
60-64
60-64
55-59
55-59
55-59
55-59
50-54
50-54
50-54
50-54
45-49
45-49
45-49
45-49
40-44
40-44
40-44
40-44
35-39
35-39
35-39
35-39
Age group (years)
30-34
30-34
Age group (years)
Age group (years)
30-34
30-34
25-29
25-29
Age group (years)
25-29
25-29
21-24
21-24
Age group
19-20
19-20
20-24
20-24
17-18
17-18
15-19
15-19
15-16
15-16
10-14
10-14
10-14
10-14
5-9
5-9
5-9
5-9
1-4
1-4
1-4
1-4
0-1
0-1
0-1
0-1
2
2.5
1.5
1
0.5
0
0.5
1
1.5
2
2.5
4
3
2
1
0
1
2
3
4
Count (thousands)
Count (thousands)
Compartment for Monitoring and Evaluation of
HIV/AIDS Infection in Romania INBI
Prof.Dr.M.Bals
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Key challenges in fertility and reproduction
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Concerns for pregnant HIV-positive women
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Confidentiality
Disclosure to children
Guilt
Family illness
Fear of transmission
Parenting issues
Secrecy and religious beliefs
Caring for a child with HIV
Adherence
Migration
Stress
Aftercare following death
Parenting through own illness
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Romanias approach for women living with HIV/AIDS

• Romanias HIV/AIDS Strategy (20112015) includes
  measures to support sexual and reproductive
  health of PLWHA
• free family planning services
• developing the capacity of PLWHA associations to
  provide counselling services to their
  beneficiaries
• Positive prevention component in all the HIV /
  AIDS treatment facilities
• developing capacity of family planning services
  to offer tailored services for PLWHA and
  serodiscordant couples

HIV/AIDS National strategy 2011-2015, in process
of approval by MOH, Romania
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HIV testing routinely available in pregnancy
Adapted from Mounier-Jack et al., HIV Med, 2008
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What about mother to child transmission?

• HIV-positive women planning to have children
  should receive pre-conception counselling on
  MTCT risks, their long-term health and the
  possible effects of ARV medication on the foetus

1BHIVA Guidelines HIV Med, 2008 2www.cnlas.ro
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Case study sharing best practice across the
region
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UK-based case study From Pregnancy to Baby and
Beyond

• This programme aimed to develop an effective and
  sustainable model for providing education,
  information and emotional and practical support
  to women with HIV at all stages of pregnancy and
  childcare
• Mothers living with HIV (Mentor Mothers) were
  trained to deliver education to the following
  groups
• Women diagnosed with HIV through ante-natal
  testing
• Pregnant women living with HIV
• Women living with HIV considering having children
• Mentor Mother training included
• One-to-one support for those managing HIV and
  treatments in pregnancy
• Workshops for women and their partners to discuss
  aspects of pregnancy
• Provision of supporting information e.g. leaflets
  and internet resources
• Support for serodiscordant couples on
  contraception and pregnancy options

Positively UK
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Feedback from women who have participated in
From Pregnancy to Baby and Beyond
If there are any issues that you want to
discuss, you bring it up...for example,
breastfeeding. Ive got some friends that are not
positive and if they see me, they keep asking me,
Why are you not breastfeeding? If I hadnt took
part in the programme I wouldnt have known what
to say.
I learned how to be happy with this situation.
And, I can live like any other woman and I can
control my health with medication. Even when I am
pregnant, I can have a negative baby, and I can
look after my baby easily.
I think its very helpful because we dont know
what is going to happen when you are HIV-positive
and get pregnant. I want to know everything. I
want to know someones experience with HIV with a
baby. I think this programme is very helpful.
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Summary

• In Europe, 34 of the new cases diagnosed in 2009
  were women, with 12.2 between 1524 years
• In Western and Central Europe unprotected
  heterosexual contact is the main route of
  transmission
• In eastern Europe the predominant route of
  transmission has shifted from IDU to heterosexual
  contact
• Romania has the largest number of long term
  survivors in Central Europe, with ages from
  1924, with implications in the future MTCT
• The European HIV / AIDS strategy should support
  sexual and reproductive health of PLWHA and the
  increase in the number of HIV tests taken by the
  general population, especially by pregnant women
  
• HIV-positive women planning to have children
  should receive pre-conception counselling on
  MTCT risks, their long-term health and the
  possible effects of ARV medication on the foetus

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• www.womenforpositiveaction.org

Women for Positive Action is supported by a grant
from Abbott