William Short MD, MPH

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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
• William.Short_at_jefferson.edu

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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.
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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.

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Module objectives

• Explain the role of the HIV primary care provider
  in preconception counseling and care
• Discuss models of integration of preconception
  care

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amfAR, n4831 US adultsemail survey (2008)
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HIV women internalize stigma around conception

• Women Living Positive Survey
• n700 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 lt 0.05)
• South (66) vs. Northeast (52) or Midwest (55),
  (p lt 0.05)
• ID (62) vs. FP/GP (62) vs. NP or PA care (48)
  (p lt 0.05)

Squires et al. (2011) AIDS patient care and STDs
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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 gt1400 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

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Fertility desires and intentions

Factors Associated with fertility desires
Positive influence Negative influence
Younger age No children Antiretroviral therapy Interventions for PMTCT Partners/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
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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 Womens Health
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Estimated of births to women with HIV
Fleming (2002) Office of Inspector General
Whitmore, et al. (2009) CROI
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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 gt35 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

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Preconception care

• Interventions that aim to identify and modify
  biomedical, behavioral and socials risks to a
  womens health or pregnancy outcomes through
  prevention and management
• Early prenatal care is not enough
• CDC. MMWR 2006551-23

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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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Unintended pregnancy
US general population 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
Finer and Henshaw (2006) Perspec Sex Repro
Health Massad (2004) AIDS Koenig (2007) AJOG
Floridia (2006) Antivir Ther
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Are HIV providers discussing reproductive desires?

• Women Living Positive Survey (n700, ARVs for 3
  years)
• 48 previously pregnant or considering pregnancy
  were never asked about their pregnancy intentions
  (n227)
• 57 currently or previously pregnant or
  considering pregnancy had not discussed treatment
  options (n239)

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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

Squires et al (2011) AIDS pt care and STDs
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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

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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

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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

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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

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Conduct preconception counseling

• Address alcohol, drugs and/or tobacco use
• Recommend avoidance of OTCs
• Consider delaying pregnancy until health is
  optimized

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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

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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

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Consider ARV treatment

• Initiate/modify ARV treatment for women who need
  it for their own health
• Consider the regimens 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.

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

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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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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

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Integrating preconception and HIV care

• 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

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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

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Integrating preconception and HIV care

• An informational brochure for clients on
  preconception health and the importance of
  preconception care

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Integrating preconception and HIV care

• Guide to preconception counseling for the HIV
  care provider

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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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Thank you!

• Contact the FXB Center with questions or
  comments, or for a copy of the slide set
• Mary Jo Hoyt
• hoyt_at_umdnj.edu