Mona Loutfy, MD

1
Women and HIV New Canadian HIV Pregnancy
Planning Guidelines

• Mona Loutfy, MD
• Maple Leaf Medical Clinic Womens College
  Hospital

2
Pregnancy planning

• Since there is
• ? mortality and morbidity overall related to HIV
  (life expectancy on average 45-50 years from
  diagnosis with ARVs)
• ? prevalence of women who are HIV-positive (51
  globally, 22 in Canada)
• Majority of HIV-positive women and men of
  reproductive age gt 80
• Methods to reduce the chance of vertical
  transmission to lt 1

Persons living with HIV are going to be
interested in PREGNANCY PLANNING
3
Fertility Desires Intentions
N 490 Ontario HIV women of reproductive age
Outcome
Fertility desired (N 475) 69 (95 CIs, 64-73)
0 31
1 32
2 37
Fertility intended (N 465) 57 (95 CIs, 53-62)
0 43
1 26
2 31
Fertility actions (N 456)
Approached partner 32
Approached doctor 26
Stopped BC to become pregnant 12
Loutfy et al. PloS ONE 2009
4
The Canadian HIV Fertility Program

• Goal
• To have the discussion of pregnancy,
  reproduction, pre-conception planning as part of
  routine HIV care Between all HCP HIV-positive
  patients
• Why
• We want pregnancies to HIV-positive women to be
  planned to improve maternal infant health, and
  reduce vertical and horizontal transmission
• Allow for discussion of contraception, sexual
  health, harm transmission reduction,
  criminalization

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Canadian HIV Pregnancy Planning Guidelines
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Counseling - Pregnancy Planning and HIV

• Fertility and HIV
• Four main issues need to be considered
• 1) Prevention of vertical transmission
• Viral transmission from the mother to the child
• 2) Healthy pre-conception
• 3) Prevention of horizontal transmission
• Viral transmission between partners or
  interacting individuals
• 4) Fertility issues
• If the individual or couple has infertility

Picture from http//www.tthhivclinic.com/overview
_home.htm 1Perinatal HIV Guidelines Working Group
2007 http//aidsinfo.nih.gov/ContentFiles/Perinata
lGL.pdf.
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Prevention of Vertical Transmission

• Guidelines July 31, 2012
• Centers for Disease Control and Prevention. U.S.
  Public Health Service Task Force recommendations
  for use of antiretroviral drugs in pregnant
  HIV-1-infected women for maternal health and
  interventions to reduce perinatal HIV-1
  transmission in the United States.
• Including use of ARVs C/S and not breastfeeding
• Up to date guidelines http//aidsinfo.nih.gov/gui
  delines

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More Potent Antiretroviral Regimens
areAssociated with Lower Perinatal Transmission
Women Infants Transmission Study, 1990-1999
Cooper, E. et al. JAIDS 200229484-94
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General Principles for Pregnancy Planning

• Taking Folic Acid 1 mg a day for 3 months before
  and during 1st trimester of pregnancy
• Not smoking and drinking
• Maintaining a balanced diet
• Terminating the use of recreational drugs

10
HIV Pre-conception Counseling

• Future mother have to stop any teratogenic drugs
  months before planned conception (e.g. Sustiva
  for at least 2 months)
• Future mother and father should not have received
  HCV treatment for 6 months before conception
• If requires ARVs for mothers health, recommended
  for woman to be taking ARVs with VL lt 50
  copies/mL before becoming pregnant

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Prevention of Horizontal Transmission

• Different clinical scenarios
• HIV woman with HIV- man (serodiscordant) or who
  is single or in same sex relationship
• HIV man and HIV- woman (serodiscordant)
• HIV man and woman (seroconcordant)
• HIV man who is single or in same sex
  relationship or couple seeking egg donation or
  surrogate mother
• Different clinical scenarios have different risk
  and require different strategies to prevent
  horizontal transmission

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All Scenarios

• Review all different options for insemination/
  conception method continuum of risk including
• Unprotected intercourse (on ART, full viral
  suppression)
• Unprotected intercourse with timed ovulation (on
  ART, full viral suppression)
• Home insemination (i.e. turkey baster method)
• Intrauterine insemination (IUI) (in fertility
  clinic)
• Sperm washing followed by IUI
• Other IVF, ICSI, gestational carrier, adoption

13
Fertility Issues

• Possibly increased in HIV Age issue
• Fertility investigations
• Options for fertility treatment
• Ovulation stimulating drugs
• Intrauterine Insemination (IUI)
• In Vitro Fertilization (IVF)
• Intracytoplasmic Sperm Injection (ICSI)

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Access to Fertility Services in Canada

• Fertility treatments available
• Any combination of Rx offered in 12/23 (52)
  clinics
• Most common IUI
• Full fertility services for HIV women
• Full services are more limited
• IVF available in only 4/23 (17) clinics
• 1 in AB, 3 in ON
• Limited treatments available for risk reduction
• Depends on couple scenario
• M/F- M-/F ?10/23 (43) M/F ?6/23 (26)
• Sperm washing - only 6/23 (26) clinics

Yudin, Shapiro, Loutfy. Reprod Health 2010
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Fertility clinic access in Quebec long story
Finally officially available - Government decide
to have one clinic providing care to patients
with infectious samples including HIV in Montreal
Dr. Jacques Kadoch CHUM Saint Luc
Hospital Gynecology Clinic Fertility
Clinic Phone [phone] ext. 2 Fax
1-514-412-7455 Entrance via Édouard-Asselin
Pavilion 264, René-Lévesque Blvd. East 6th
Floor Montreal (Quebec) H2X 1P1
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Pamphlets Pregnancy Planning

• Available in French English at www.catie.ca

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Acknowledgements

• Thank you to Anita, Benoit, Nadia OBrien,
  Johanna Lewis Women for Positive Action for
  help with the slides
• Thank you to CHIWOSs co-PIs, and the entire
  national core research team
• Also to the PRAs, Steering Committee members
• Thank you to the Research Team, CAB members and
  collaborators
• Thank you to Canadian Institutes of Health
  Research, Womens College Hospital and the
  University of Toronto
• Thank you to our affiliates CANOC and Reach
• Thank you to our funders CIHR and CTN