PRECONCEPTION AND
REPRODUCTIVE HEALTH FOR
WOMEN AND MEN LIVING
WITH HIV
Shannon Weber, MSW
Judy Levison, MD, MPH
Mary Jo Hoyt, MS, FNP
2012 FTCC Meeting
What is preconception care it and why
should we care about it?
Shannon Weber, MSW
Disclosures

We have no financial disclosures.
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
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
Estimated number of births to women
living with HIV infection, 2000-2006
9000
8500
8000
7500
7000
6500
6000
5500
2000
2001
2002
2003
High Estimate
2004
2005
Low Estimate
Office of Inspector General (Fleming), 2002
Whitmore, et al. CROI, 2009
2006
amfAR email survey of US adults,
n=4831 (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

Squires et al. AIDS PATIENT CARE and STDs 2011
Reduce stigma, normalize desires
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
Hey, Mom………
Unintended pregnancy
US general population
US,
232 HIV+ women
WIHS
US
1090 HIV+
adolescents
49% pregnancies unintended
77% pregnancies while using
contraception (vs. 60% HIV-)
83.3% unplanned
49-52% HIV status known
Italy
57.6% unplanned
334 HIV+ on ARV
Finer/Henshaw Perspec Sex Repro Health 2006;
Massad AIDS 2004; Koenig AJOG 2007; Floridia
Antivir Ther 2006
Men’s sexual and reproductive health
http://www.cicatelli.org/titlex/downloadable/MaleGuidelines2009.pdf



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
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.
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
Preconception Care Case Studies
Judy Levison, MD, MPH
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
Role
Play!
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

Case 1—Roberta…

You ask about contraception.

She previously used oral contraceptives and asks
about restarting them.

How do you counsel her?
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
Condoms

The one method that protects against STDs and
provides contraception

How do your clients feel about using male
condoms? Female condoms?
Male condoms
Female condoms
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
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.
Contraception
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.
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
IUDs(2)
Permanent sterilization

Laparoscopic tubal ligation

Essure (hysteroscopically placed coils in tubes)

Postpartum tubal ligation

Vasectomy
Laparoscopic tubal ligation
Essure
Postpartum tubal ligation
Vasectomy
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
The Serodiscordant Couple
Role
Play!
Case 2--Julia

Julia is 31, HIV+, diagnosed 2
years ago after ending a
relationship with an HIV-infected
partner

No history of HIV-related illness

Not on HIV medications

CD4 in the 600's

VL is 65, 000

New partner is HIV-uninfected

Seems anxious and upset

Plan:

Discuss pros and cons of starting
HIV treatment

Recommend HIV testing for partner

Reinforce the importance of using
condoms.

Refer to a support group

Re-check her VL and CD4 in 3
months.

Continue to evaluate for and
discuss HIV treatment
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?
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.


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

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
Serodiscordant couples

If the woman is HIV+ and the man is HIV-, discuss
the options of:
Ovulation predictor kits
 Home insemination (“turkey baster method”)

Ovulation predictor kits
These replace the old basal body temperature charts
When the time is right, the choices are:

Home insemination with partner’s semen
The “turkey baster” method
*A needle-less syringe works fine
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.
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.
Role
Play!
Case 3—Richard


32 year old HIVpositive male
diagnosed with HIV 3
years ago,
On ARVs. CD4 600 and
VL<48 (undetectable)


Excited about plans to
get married next
month to a woman he’s
been dating for a year
Plan:
 Refill
medications
 Counsel on use of
condoms
 Return in 6 months
Case 3—Richard

You ask Richard whether his fiancee has been
tested for HIV
 He

You ask whether they are thinking about having
children
 He

says, “Yes, and she is HIV-negative.”
tells you, “Yes, sooner rather than later.”
How do you counsel him?
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
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
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.
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
How can contraceptive and preconception
care be integrated into routine care?
Mary Jo Hoyt, MSN
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
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
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
Guidelines
Number 117, December 2010
Gynecologic Care for Women With Human
Immunodeficiency Virus
Guidelines
Recommendations for Use of Antiretroviral Drugs in
Pregnant HIV-1-Infected Women for Maternal
Health and Interventions to Reduce Perinatal HIV
Transmission in the United States
 Preconception
Counseling and Care for HIV-Infected
Women of Childbearing Age
 Reproductive Options for HIV-Concordant and
Serodiscordant Couples
http://www.aidsinfo.nih.gov
Training

This site will offer self-study modules (CEUs/CMEs
available) covering ACOG guidelines on
reproductive health care in the context of HIV.
http://womenandhiv.org
[Coming soon]
Training
Webinar
Self-study
modules

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 • http://www.fxbcenter.org/

• http://www.aids-etc.org
Support tools: Patient Brochure
Support Tools: EPIC Template


Are you interested in having a child?
When do you wish to conceive?



Are you currently using condoms?
Are you currently using contraceptive other than condoms:?




Currently 6 mos-1yr, 1-2 years; >2years
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?
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
Support tools: Client questionnaire
Support tools: Provider Checklist
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.
Support tools: Guidelines for Use of
ARV Therapy in Pregnancy
Clinical tools: Guidelines for Use of ARV
Therapy in Pregnancy
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 sweber@nccc.ucsf.edu
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
Speaker contact information
Shannon Weber, MSW
National HIV/AIDS Clinicians' Consultation Center
sweber@nccc.ucsf.edu
Judy Levison, MD, MPH
Baylor College of Medicine
jlevison@bcm.edu
Mary Jo Hoyt MSN, FNP
FXB Center, UMDNJ
AETC National Resource Center
hoyt@umdnj.edu