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@jefferson.edu
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.
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 HIVinfected men.
Describe preconception assessment and
interventions for women living with HIV.
Module objectives

Explain the role of the HIV primary care provider in
preconception counseling and care

Discuss models of integration of preconception
care
amfAR, n=4831 US adults
email survey (2008)
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
Caucasian (67%) vs. Hispanic (53%), (p < 0.05)
 South (66%) vs. Northeast (52%) or Midwest (55%), (p < 0.05)
 ID (62%) vs. FP/GP (62%) vs. NP or PA care (48%) (p < 0.05)

Squires et al. (2011) AIDS patient care and STDs
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 >1400 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
Fertility desires and intentions
Factors
Associated with fertility desires

Positive influence
Negative influence
•
•
•
•
•
•
•
•
•
•
Younger age
No children
Antiretroviral therapy
Interventions for PMTCT
Partner’s/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
Contraceptive Use Among US Women with HIV
Women's
Interagency HIV
Study (WIHS):
In over 30% of
these visits, HIVinfected women
reported not
using any form of
contraception.
Massad et al. (2007)
J Women’s Health
Estimated # of births to women with HIV
9000
8500
8000
7500
7000
6500
6000
5500
2000
2001
2002
2003
High Estimate
2004
2005
2006
Low Estimate
Fleming (2002) Office of Inspector General
Whitmore, et al. (2009) CROI
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 HIVwomen 15-44 years
Largest difference (306% increase) was seen in women
>35 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
Preconception care


“Interventions that aim to identify and modify
biomedical, behavioral and socials risks to a
women’s health or pregnancy outcomes through
prevention and management”
Early prenatal care is not enough
CDC. MMWR 2006;55:1-23
Goals of preconception care in
the context of HIV infection
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


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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
Importance of preconception care
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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
Unintended pregnancy
US general population
US,
232 HIV+ women
WIHS
49% pregnancies unintended
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
Are HIV providers discussing reproductive
desires?

Women Living Positive Survey (n=700, ARVs for 3+
years)
 48%
previously pregnant or considering pregnancy
were never asked about their pregnancy intentions
(n=227)
 57% currently or previously pregnant or considering
pregnancy had not discussed treatment options
(n=239)
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.
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
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
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
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
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

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Risks/benefits of HIVrelated medications
Disclosure of HIV
diagnosis
Partner testing
Safer conception
options
Conduct preconception counseling

Address alcohol, drugs and/or tobacco use

Recommend avoidance of OTCs

Consider delaying pregnancy until health is optimized
Optimize preconception health
Screen for:

Syphilis
Provide:


Refer for:

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Genetic screening, based on
history
Contraception, as needed,
to delay pregnancy while
health issues are addressed
Folic acid 400 mcg daily
Immunizations, as
needed, for:
 hepatitis B
 rubella
 varicella
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
Consider ARV treatment

Initiate/modify ARV treatment for women who need it for
their own health:

Consider the regimen’s 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.
How can preconception care be
integrated into the HIV primary care
setting?
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
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
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
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
Integrating preconception and HIV care

An informational
brochure for clients
on preconception
health and the
importance of
preconception care
Integrating preconception and HIV care

Guide to
preconception
counseling for
the HIV care
provider
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
Thank you!
Contact the FXB Center with questions or comments, or for a
copy of the slide set:
Mary Jo Hoyt
hoyt@umdnj.edu