Transcript Document
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 [email protected] 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 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 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 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: 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 [email protected]