Transcript Preconception Care and Contraception for HIV

Deborah Cohan, MD, MPH
Associate Professor
University of California San Francisco
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I have no financial disclosures.
Describe the elements of a preconception
evaluation for HIV+ women who desire
conception
 Discuss counseling points to review during a
preconception visit with an HIV+ woman
 Describe a safe method of conception for
HIV+ woman/HIV- man serodiscordant
couple.
 List the pros/cons of various contraceptive
methods for HIV+ women
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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
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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. AIDS PATIENT CARE and STDs 2011
US reproductive-aged women
Cross-sectional, Rochester
n=118
Cross-sectional,
n=182
Cross-sectional,
n=181
Probability
sample, n=1421
(34,833 women,
53,177 men)
British
Columbia
35%
20% yes, 15% unsure
12% of previously sterilized
(4% tubal regret in US)
25.8%
Baltimore
59%
US, HCSUS
29% women
28% men
¹Chen Fam Plann Persp 2001, ²Stanwood Contraception 2007, ³Ogilvie AIDS 2007, 4Oladapo J Natl Med
Assoc 2005, Finocchario-Kessler AIDS Behav 2010
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“Being infected with HIV dampens but
does not come close to eliminating
individuals’ desires and intentions to have
children.”
US general population
US,
232 adults
WIHS
US
1090 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 on ARV
Finer/Henshaw Perspec Sex Repro Health 2006; Massad AIDS 2004; Koenig
AJOG 2007; Floridia Antivir Ther 2006
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WHO?
 Every reproductive-aged women
 Even if amenorrhea, no current male sexual
partner
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WHEN?
 Early and Often
▪ Puts the issue “on the map”
▪ New life circumstances/partners, new medications
(drug-drug interactions), new developments in HIV
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HIV history
 Nadir/current CD4, viral load, ARV hx, resistance
 Disclosure, adherence
 Serostatus of children
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Medication review (HIV, non-HIV, OTC)
Medical hx
 Asthma, DM, HTN, obesity, HBV, HCV
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Reproductive hx
 STIs, dysplasia/Tx, prior pregnancy outcomes, sexual, contraceptive,
menstrual, infertility hx
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Social hx/Habits
 EtOH, drug, nicotine, nutrition/exercise
 Violence/abuse, social support
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Family genetic history
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Pregnancy impact on HIV
ARV efficacy
 Sexual transmission (92%  with ARV)
 Perinatal (0.4% if VL <500 at delivery)
 Adherence and disclosure
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ARV safety
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Avoid preconception/1st trimester EFV
Caution with d4T/ddI
Avoid NVP initiation if CD4 > 250
ARVs and PTD
▪ Preconception/1st trimester: OR 1.71 (1.09-2.67)
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Pros/cons of ARV initiation preconception vs. 2nd
trimester
Donnell Lancet 2010; Tubiana CID 2005; Hitti JAIDS 2004; Shapiro NEJM 2010; Kourtis
AIDS 2007
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<200: TMP-SMX
  risk NTD, CV and urinary defects
 Folic acid (mostly 6mg)
▪ CV anomalies OR 1.24 (0.94-1.62)
▪ Multiple anomalies OR 6.4 (none) to 1.9 (+ folic acid)
▪ BUT…  risk TMP-SMX prophylaxis/Tx failure
 Defer pregnancy until d/c TMP-SMX?
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<50: Azithromycin vs. clarithromycin
DHHS Guidelines 2010 (aidsinfo.nih.gov); Hernandez-Diaz 2000; Czeizel 2001;
Hernandex-Diaz 2001; Safrin 1994; Razavi 2002
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Co-infections
 HBV (2 active NRTIs)
 HCV
▪ 10-20% transmission
▪ RBV = category X
 Avoiding incident CMV, Toxo
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Prenatal/postnatal care
 Genetic testing
 Delivery route (TOL if VL < 1000)
 Infant feeding, AZT prophylaxis, HIV testing
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Optimizing health
 Vaccination, diet/exercise, smoking/drug use
 Psychosocial referrals
 Contraception
Tovo CID 1997, Gibb Lancet 2000, Alter 2006; Polis CID 2007; Ng-Giang 2010
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HCSUS, (1996 data)
 Currently married or with heterosexual partner
HIV+ MEN
HIV + WOMEN
POS
NEG
UNK
54%
52%
Chen et al. Family Planning Perspectives, 2001
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1. Predict ovulation (kit, BBT, cervical mucus)
2. Ejaculate into cup or spermicide-free condom
3. Home insemination with 5-10 cc syringe
+
or
+
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32 yo G4P1T3 coming for her routine HIV
appointment.
On TDF/FTC/DRV/r
Irregular menses but no other complaints
She is sexually active with HIV-negative
male partner of 4 months.
Uses condoms “always”
Withdrawal/Rhythm
19%
9%
Diaphragm
20%
6%
Condom
14%
3%
Pill
0.5%
Copper IUD
0.8%
Tubal Ligation
0.5%
Injectable Progestin
Implants
Vasectomy
Typical
Lowest Expected
0.2%
0.1%
0.02%
0%
5%
10%
15%
20%
Hatcher: Contraceptive Technology 16th Edition 1994.
1.
2.
3.
4.
5.
Combined oral contraceptive pill
Vaginal ring
Depo-provera (DMPA)
Intrauterine device (IUD)
IUD or DMPA
NO CHANGE
 TDF (FEM-PrEP?)
 RAL
 HORMONE LEVELS
 EFV (400mg): EE AUC 
 ETR
 ATV
 IDV
 HORMONE LEVELS
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EFV (600mg): NG AUC 
NVP
APV
DRV/r
LPV/r
NFV
RTV
TPV/r
El-Ibiary Eur J Contracept Reprod Health Care. 2008, Sevinsky Antivir Ther 2011,
Anderson Br J Clin Pharmacol. 2011
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No Δ DMPA levels among women on:
 NFV
 NVP
 EFV
 Other PIs?
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No Δ CD4 or viral load with DMPA
Cohn Clin Pharm Ther 2007; Nanda Fertil Steril 2008; Watts Contraception 2008
Cohort
Kenya,
n=248
DMPA vs none @ HIV  viral set-point (0.33log), lower
acquisition
CD4
Cohort
Kenya,
n=283
DMPA vs OCP vs
none postpartum
Cohort
Multicenter, Impant/inject vs. OCP No difference in progression
n=4109
vs none
(ART-eligible/death)
RCT
Zambia,
n=595
IUD vs. DMPA vs.
OCPs, ARV-naïve
 Progression (CD4<200/death)
DMPA (AHR 1.6; 1.2-2.3), OCP
(AHR 1.7; 1.1-2.5) vs. IUD
Cohort
Uganda,
Zimbabwe,
n=303
DMPA vs OCP vs
none after
seroconversion
No difference in progression to
AIDS (CD4<200 or WHO 3/4)
No difference in viral load, CD4 to
24 mos postpartum
Any impact probably mitigated by HAART
Baeten AIDS 2005, Richardson AIDS 2007, Stringer AIDS 2009, Morrison JAIDS 2011
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No evidence of  infectious complications
 156 HIV+, 493 HIV- (Kenya; Copper IUD)
 Overall complications @ 24 mos: HR 1.0 (0.6-1.6)
 PID: 2% for HIV+ vs. 0.4% for HIV- (p=0.09)
Morrison BJOG 2001; Sinei
Lancet 1998; Richardson
AIDS 1999; Heikinheimo
Human Repro 2006
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No evidence of  infectious complications
 156 HIV+, 493 HIV- (Kenya; Copper IUD)
 Overall complications @ 24 mos: HR 1.0 (0.6-1.6)
 PID: 2% for HIV+ vs. 0.4% for HIV- (p=0.09)
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No evidence of  genital tract shedding of HIV
 Copper IUD n=98 (Kenya): 4 mos s/p insertion: OR 0.6 (0.3-1.1)
 LNG-IUS (Mirena) n=12: no difference pre vs. post-insertion
▪ 10/12 on HAART
▪ On-going studies
Morrison BJOG 2001; Sinei
Lancet 1998; Richardson
AIDS 1999; Heikinheimo
Human Repro 2006
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No evidence of  infectious complications
 156 HIV+, 493 HIV- (Kenya; Copper IUD)
 Overall complications @ 24 mos: HR 1.0 (0.6-1.6)
 PID: 2% for HIV+ vs. 0.4% for HIV- (p=0.09)
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No evidence of  genital tract shedding of HIV
 Copper IUD n=98 (Kenya): 4 mos s/p insertion: OR 0.6 (0.3-1.1)
 LNG-IUS (Mirena) n=12: no difference pre vs. post-insertion
▪ 10/12 on HAART
▪ On-going studies
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WHO Medical Eligibility Criteria category 2
 Benefits generally outweigh theoretical or proven risk
 AIDS, but NOT “clinically well on ARV” category 3 for insertion
▪ Not recommended unless other methods not available/not acceptable
Morrison BJOG 2001; Sinei
Lancet 1998; Richardson
AIDS 1999; Heikinheimo
Human Repro 2006
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Comprehensive sexual hx and determine
fertility desires
Preconception visit = harm reduction
 Validating fertility desires
 Optimize woman’s health
 Prevent perinatal and sexual HIV transmission
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Contraception visit
 Consider drug-drug interactions with hormones
 Promote long-acting reversible methods
▪ IUD = underutilized option
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National Perinatal HIV Hotline (24/7)
 (888) 448-8765
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UCSF RID Pager (24/7)
 (415) 443-8726

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“Do we have to fill our patients’ lives with
years or those years with life?”
Augusto Enrico Semprini