Transcript HIV in Pregnancy - CHOICES - Memphis Center For Reproductive

REPRODUCTIVE CHOICE AND
FAMILY PLANNING
FOR PERSONS LIVING WITH
HIV/AIDS
Nikole D. Gettings, BS, RN, MSN, CNM, APN
ACTIVITY PLANNING COMMITTEE
 Medical Review Committee
 Donna Randolph, MD, CHOICES Medical Director
 Bev Byrum, MSN, NP, Adjunct Faculty, Vanderbilt School of Nursing
 Nikole Gettings, MSN, CNM, CHOICES Clinic Services Director
 Patricia M. Flynn, MD, Member, St. Jude Faculty, Arthur Ashe Chair in Pediatric
AIDS Research, Director, Clinical Research, Infectious Diseases, Director, Translational
Trials Unit, Co-Leader, HIV Therapeutics & Vaccine Development, CIDC
 Victoria Harris, Ed.D. Director of Education, TN AIDS Education & Training Center,
Vanderbilt Comprehensive Care Clinic
 Project Administrative Coordination:
 Lanita Williams, MPH, ARHP Program Manager
 Katherine Leopard, CHOICES Community Partners Coordinator
 Jennifer Pepper, CHOICES Assistant Director
LEARNING OBJECTIVES:
AFTER TODAY’S PRESENTATION THE LEARNER WILL:
Discuss the reproductive life needs of persons living with HIV
and demonstrate the ability to assist patients to develop an
effective reproductive life plan.
2. Explain to patients the most effective contraception options and
the specific drug interaction between HAART and hormonal
birth control methods.
3. Provide counseling tips regarding pregnancy options for persons
living with HIV in a non-directive way including healthy
preconception practices.
4. Identify local and national resources for reproductive health care
for persons living with HIV.
1.
HIV STATISTICS (2007)
MCGOWAN, PEPPER, GETTINGS, CAPECE
AND RINSDALE, 2014
Has Your HIV Medical Provider talked to you
about Pregnancy Planning
Yes
41%
No
59%
Case Study # 2:
When are you planning
a pregnancy?
Kayla
• 37 yo AA female, presents
for annual GYN and STI
Screening
• Sexually Active
• Was on Depo with PCP;
unsure of why depo was
stopped about 9+ months
prior
• Does not want any
additional pregnancies
Case Study # 2:
When are you planning
a pregnancy?
Kayla
PMH
Medications
Family History
Social History
Sexual Health History
DEVELOPING A REPRODUCTIVE LIFE PLAN:
PREGNANCY PLANNING
When do you want to plan a pregnancy?
How many pregnancies or children would you
like to plan?
Are there health issues you should address
before planning a pregnancy?
Do you have special medical needs you will
need care for during a pregnancy to protect
the health of yourself or your baby?
Ezeanolue, E., et al (2011); Squires, et al., (2011) ; MMWR June 2013; MMWR April 2014
DEVELOPING A REPRODUCTIVE LIFE PLAN:
PREGNANCY PREVENTION
How do you want to prevent a pregnancy?
 How long do you want to prevent a pregnancy?
 What would you do if a pregnancy occurred now?
 What has worked well for you in the past?
 What have you heard about?
 What did you like or not like about a previous method?
 Partner involvement in decision making?
 Special Medical or health issues?
MMWR June 2013; MMWR April 2014
DEVELOPING A REPRODUCTIVE LIFE PLAN:
PATIENT DECISION FACTORS
Cost
Side effects
Delivery Method
Control
How long will it work
Effectiveness
MMWR June 2013; MMWR April 2014
DEVELOPING A REPRODUCTIVE LIFE PLAN:
CLINICIAN DECISION FACTORS
Fertility Desire
Medical History and co-morbidities
Age
Smoking Status
Access to healthcare
Adherence to healthcare
Decision making ability
MMWR June 2013; MMWR April 2014
CATEGORIZING CONTRACEPTION
Hormonal
Non Hormonal
Pill
 Withdrawal
Patch
 Spermicide
Ring
 Condom (Male and Female)
Medroxyprogesterone
 Copper Intrauterine Device
Levonogestral
 Sterilization
Intrauterine Device
 Male
 Female
CATEGORIZING CONTRACEPTION
Short Acting
Long Acting
Withdrawal
Medroxyprogesterone
Spermicide
Levonogestral
Condoms (Male and
Female)
Pills
Patch
Ring
Intrauterine Device
Copper Intra Uterine
Device
Sterilization
Male
Female
WHO ELIGIBILITY CRITERIA FOR
STARTING CONTRACEPTION
 WHO 1: Can use the method. No restrictions to use
 WHO 2: Can use the method. Advantages generally outweigh the
theoretical or proven risks. If method is chosen, more than usual
follow up may be indicated.
 WHO 3: Should not use the method unless clinician makes clinical
judgment that patient can safely use it. Method of last choices, for
which regular monitoring may be indicated.
 WHO 4: Should not use method. Condition represents an
unacceptable risk if method is used.
QUALITY OF EVIDENCE
 I: Evidence obtained from at least one properly designed randomized
controlled trial.
 II-1: Evidence obtained from well-designed controlled trials without
randomization.
 II-2: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research
group.
 II-3: Evidence obtained from multiple time series with or without the
intervention. Dramatic results in uncontrolled experiments also could
be regarded as this type of evidence.
 III: Opinions of respected authorities, based on clinical experience,
descriptive studies, or reports of expert committees.
U.S. Preventative Services Task Force
QUALITY OF RECOMMENDATIONS BASED
ON RESEARCH
Level A: Recommendations are based on good
and consistent scientific evidence
Level B: Recommendations are based on
limited or inconsistent scientific evidence
Level C: Recommendations are based primarily
on consensus and expert opinion.
American College of Obstetricians and Gynecologists, 2010
GUIDELINES
CDC: MMWR
 U.S. Selected Practice
Recommendations for
Contraceptive Use, 2013 Vol. 62,
No. 5; June 21, 2013
 Providing Quality Family
Planning Services:
Recommendations of the CDC
and the U.S. Office of
Population Affairs,Vol. 63, No. 4;
April 25 2014
American College of Obstetricians
and Gynecologists
 ACOG: 2010
 Practice Bulletin No. 117, Dec.
2010
 The care of HIV-infected
Woman
CONTRACEPTION AND HIV: SPECIAL
FACTORS
Pregnancy Prevention Effectiveness
Risk of HIV infection acquisition
Risk of HIV progression
 Risk of increase viral load of HIV
 Risk of decrease CD-4 count
Risk of infectious complications
Additional risk of STI vulnerability
Risk of overall complications
Risk of increased transmission rate of HIV to
partner(s)
ACOG, 2010; Ezeanolue, et al., 2011
LARC: INTRAUTERINE DEVICES
(IUDS)
 WHO Category 2
 No difference in complications between HIV+, clinically well, and
HIV- women
 Higher rate of efficacy than combined oral contraceptives
 No adverse effects on CD4 count
 No association between IUD and HIV transmission: No increased
genital shedding of HIV RNA
 Women with advanced immunosuppression: WHO 3, monitor
closely for signs of infection
Kapiga 1998, Morrison 2001; Heikinheimo, et al. 2006; Richardson et al, 1999
LEVONOGESTRAL INTRAUTERINE SYSTEM
Levonorgestrel-containing (Mirena and Skyla): Studies are
limited, but growing body of evidence continues to
support use with same WHO criteria as Copper IUD: 2/3
• Limited studies show no known drug interactions for
women on HAART
• No increase in HIV RNA genital shedding
• No decrease in CD4
Lehtovirta, P, et al., 2007; Heikinheimo, et al., 2006
IUD PATIENT COUNSELING PEARLS:
COPPER IUD (PARAGARD)
Primary mechanism is copper ion effects on
sperm
1-10 year
Cost effective
No Hormonal Side Effects
Menstrual bleeding
Ongoing Evaluation: Annual or symptom based
Hatcher, et al., Contraceptive Technology, 2007.
IUD PATIENT COUNSELING PEARLS:
LEVONOGESTREL INTRA-UTERINE SYSTEM
 Primary mechanism: thickens cervical discharge to inhibit
sperm mobility
 Secondary mechanism: ovulation inhibition and resultant
endometrial thinning
 1-5 years
 Cost effective
 Hormonal Side Effects
 Bleeding Pattern
 Evaluation: Annual or symptom based
Hatcher, et al., Contraceptive Technology, 2007
LARC: LEVONORGESTREL – IMPLANT
(NEXPLANON/IMPLANON)
WHO Category: 1
Specific Studies are very
limited
Similarities to other hormonal
methods
Fakoya 2008
LEVONORGESTREL IMPLANT: PATIENT
COUNSELING PEARLS
 Primary mechanism: thickens cervical discharge to inhibit sperm
mobility
 Secondary mechanism: ovulation inhibition and resultant
endometrial thinning
 May be used for 1-3 years
 Provider Training
 Implantation: Needle
 Removal: small incision
 Bleeding pattern
 Other hormonal side effects; scarring with insertion or removal
 Evaluation: Redness, persistent pain at site of insertion
Hatcher, et al., (2007), Contraceptive Technology;
LARC: MEDROXYPROGESTERONE ACETATE
(DEPO PROVERA)
 WHO Category: 1
 No risk of HIV disease progression
 No adverse effects on CD4 count or viral
load
 Inconsistent results regarding hormonal
contraceptive and increased risk of HIV-1
DNA or RNA shedding from genital tract.
 Weight Gain/Loss
 Bone Mineral Density
 Fat Re-Distribution
 Minimal to no drug interactions
Watts 2008, Yin 2005, Brown 2007
MEDROXYPROGESTERONE ACETATE: PATIENT
COUNSELING PEARLS
 Primary Mechanism of Action: Primary
mechanism: thickens
cervical discharge to inhibit sperm mobility
 Secondary mechanism: ovulation inhibition and resultant
endometrial thinning
 3 month intervals (13 weeks)
 Delivery method: Shot, unable to remove once administered
 Cost Effective
 Hormonal Side Effects
 Bleeding Pattern
 Other Side Effects: Headaches, depression
 Weight
 Calcium Supplementation
Hatcher et al., Contraceptive Technology, 2007; Watts, et al., 2008
SHORT ACTING HORMONAL METHODS:
THE PILL, PATCH, AND RING
WHO Category 1
Attention to drug interactions with HAART and ARV
Risk of HIV progression, CD4 count, viral load and risk
of transmission as well as HIV-1 genital shedding are
similar to other hormonal methods
Panel on Antiretroviral Guidelines for Adults and Adolescents 2008; World Health
Organization, 2010;
HORMONAL SHORT ACTING
COUNSELING PEARLS
 Primary mechanism: thickens cervical discharge to inhibit
sperm mobility
 Secondary mechanism: ovulation inhibition and resultant
endometrial thinning
 Delivery Method: Patient controlled daily, weekly or monthly
 Effectiveness: Compared to other methods
 Bleeding Patterns
 Other Side Effects
 Drug Interactions
Hatcher, et al., (2007), Contraceptive Technology
EMERGENCY CONTRACEPTION
Interactions with ART have not been studied
• British recommendations: double-dose
Copper IUD placement
• Especially for women who present 4-5 days after
intercourse
Stewart 2007, Fakoya 2008
CONTRACEPTION AND HIV: DRUG
INTERACTIONS
Increased steroid dosage (contraception)
P450 Metabolism
Increased ART medication dosage
Decrease steroid dosage (contraception)
Decrease ART Medication dosage
Complicated interactions
Adverse side effects
ACOG, 2010; WHO, 2010
DRUG INTERACTIONS TO CONSIDER
Drug Interactions
•
Efavirenz® is not recommended for use by women
with childbearing potential
- UNLESS- Two effective methods of contraception
are used together
• Birth defects have been seen with use of Efavirenz®
(Sustiva® and Atripla®)
• Fosamprenavir (Lexiva®) is not recommended for use
together with hormonal contraceptive
ACOG, 2010; http:www.hiv-druginteractions.org;
http://hivinsite.ucsf.edu/insite?page=ar-00-02; WHO, 2010
CONTRACEPTION AND HIV: GENERAL
DRUG INTERACTIONS SUMMARY
 Contraception Hormonal Metabolism
 Ritonavir-Boosted Protease Inhibitors: Decrease hormonal contraceptive
efficacy
 Non-Nucleoside Reverse Inhibitor: Contraceptive Efficacy may be affected:
 Nevirapine
 Atazanavir or indinavir
 Efavirenz
 Anti-Retro Viral Effects
 Ritonavir: Liver transaminases
 Tipranavir/Ritonavir: Increased skin and musculoskelatal adverse events;
possible increased drug hypersensitivity
DRUG INTERACTIONS TO CONSIDER
• Studies are limited and type specific
• Aptivus® (tipranavir)
• Kaletra® (lopinavir/ritonavir)
• Norvir® (ritonavir)
• Prezista® (darunavir/ritonavir)
• Lexiva® (Telzir/fosamprenavir)
• Viracept® (nelfinavir)
• Viramune® (nevirapine)
• Rifabutin®
• Rifampin®
ACOG, 2010; http:www.hiv-druginteractions.org;
http://hivinsite.ucsf.edu/insite?page=ar-00-02; WHO, 2010
Case Study # 2:
When are you planning
a pregnancy?
Kayla
• Does Kayla want a
pregnancy?
• Is Kayla at risk for
pregnancy?
• Does Kayla have any
contraindications to
pregnancy?
Case Study # 2:
When are you planning
a pregnancy?
Kayla
• Which
contraception(s) have
the least
contraindications for
Kayla?
• A) Paragard IUD
• B) OCP
• C) Depo
• D) Either A or C
Case Study # 2:
When are you planning
a pregnancy?
Kayla
• Which
contraception(s)
would be the MOST
effective for Kayla?
• A) Depo
• B) IUD
• C) Pills
• D) Condoms
Case Study # 2:
When are you planning
a pregnancy?
Kayla
• Which
contraception(s) could
you start Kayla on
today?
• A) Depo
• B) IUD
• C) Essure
• D) Condoms
Case Study # 2:
When are you planning
a pregnancy?
Kayla
• Kayla chooses Depo
today. What exam(s)
are necessary before
you initiate depo?
• A) STI Screening
• B) PAP Smear
• C) Pregnancy Test
• D) None of the above
Case Study # 2:
When are you planning
a pregnancy?
Kayla
• Do you have any
other concerns for
Kayla that you may
want to address
today?
• Social Behavioral
• Mental Health
• Violence/Abuse
Case Study # 2:
When are you planning
a pregnancy?
Kayla
• What are the key
teaching points you
want to emphasize to
Kayla before she
leaves today?
• Given Kayla’s PmHx,
are there any specific
tools that may be
more/less helpful in
providing education?
RESOURCES
 CHOICES www.memphischoices.org
 HIV Treatment Guidelines www.aidsinfo.nih.gov
 Birth Control Fact Sheets http://www.birth-controlcomparison.info/
 The Well Project www.thewellproject.com
 Providing Quality Family Planning Services: Recommendations of
CDC and the U.S. Office of Population Affairs (April 2014). MMWR
Recommendations and Reports,Vol 63, No 4.
 CME: http://www.cdc.gov/mmwr/cme/conted.html
 ARHP: Birth Control CME emails
 ARHP:The Bedsider
 Reproductive Life Planning Tool Examples
 http://dhss.delaware.gov/dph/chca/files/adultlifeplan2011.pdf
 http://everywomannc.com/sites/default/files/documents/Are%20You%20Ready%20-
%20Sex%20And%20Your%20Future.pdf
 http://famplan.org/Resources/Docs/adult_rhp_busy_woman.pdf
 http://famplan.org/Resources/Docs/teen_rlp.pdf
REFERENCES
 Aaron, E., Criniti, S., (2007). Preconception health care for HIV-infected women. Topics in
HIV Medicine; 15(4): 137-141.
 American College of Obstetricians and Gynecologists [ACOG]. Committee on Practice
Guidelines- Gynecology. (December 2010). Practice Bulletin Number 117: Gynecologic
care for women with human immunodeficiency virus. Obstetrics & Gynecology; 116 (6) : 14921509.
 American Society for Reproductive Medicine, The Ethics Committee (2010). Human
immunodeficiency virus and infertility treatment. Fertility and Sterility; 94(1): 11-15.
 American Society for Reproductive Medicine [ASRM]. The practice Committee (2008).
Guidelines for reducing the risk of viral transmission during fertility treatment. Fertility and
Sterility; 90(Supplement 3): S156-62.
 Castano, P., (2007). Use of intrauterine devices and systems by HIV-infected women.
Contraception, 75: S51-S54.
 Centers for Disease Control and Prevention. (June 2013)U.S. Selected Practice
Recommendations for Contraceptive Use, 2013: Adapted from the World Health
Organization Selected Practice Recommendations fro Contraceptive Use, 2nd Edition.
MMWR 62:5.
 Centers for Disease Control and Prevention [CDC]. U.S. Medical eligibility criteria for
contraceptive use, 2010. Morbidity and Mortality Weekly Report. 2010: 59.
REFERENCES
 Ezeanolou, E., Stumpf, P., Soliman, E., Fernandez, G., Jack, I., (2011). Contraception choices
in a cohort of HIV+ women in the era of highly active antiretroviral therapy. Contraception,
84:94-97.
 Fakoya, A, et al. (2008). BHIVA, BASHH & FSRH guidelines on sexual and reproductive
health. British HIV Association. HIV Medicine, 9: 681-720.
 Gavin, L..; Moskosky, S. ; Carter, M., et al. (2014) Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs. MMWR 63 (4): 1-54.
 Hatcher, R., Trussell, J., Nelson, A., Cates, W., Stewart, F., Kowal, D. Contraceptive Technology.
19th ed. 2007. Ardent Media, INC., New York, NY.
 Heikinheimo, O., Llehtovirta, P., Suni, J., Paavonen, J., (2006). The levonorgestrel-releasing
intrauterine system (LNG-IUS) in HIV-infected wommen: effects on bleeding patterns,
ovarian function and genital shedding of HIV. Human Reproduction, 21: 2857-2861.
 Horton, R., Gettings, N., Marshall, J., (2009). Abstract: Integration of HIV prevention and
reproductive health services. Contraception, 80: 220, P80.
 Jain, A.K., (2012). Hormonal Contraception and HIV acquisition risk: implications for
individual users and public policies. Contraception, 86:645-652.
REFERENCES
 Lehtovirta, P., Paavonen, J., Heikinheimo, O., (2007). Experience with the levonorgestrel-releasing intrauterine system
among HIV-infected women. Contraception, 75: 37-49.
 Leticee, N., Viard, J., Yamgnane, A., Karmochkine, M., Benachi, A., (2012). Case Report: Contraceptive






failure of etonogestrel implant in patients treated with antiretrovirals including efavirenz. Contraception,
85: 425-427.
MacGowan, T., and Marshall, J. (unpublished): Memphis Center for Reproductive Health, Documenting
the Reproductive Health Care Needs of HIV-Infected Women in Memphis, TN: An Interview Survey, a
convenience sample of 69 WLWHA, ages 17-44.
Morrison, et al. (2001). Is the intrauterine device appropriate contraception for HIV-1-infected
women?. British Journal of Obstetrics and Gyneaecology, 108 (8): 784-790.
New York State Department of Health AIDS Institute, in Collaboration with the Johns Hopkins
University Division of Infectious Disease, HIV Clinical Guidelines. Available at
http://www.hivguidelines.org/clinical-guidelines/womens-health/preconception-care-for-hiv-infectedwomen/. Accessed (12/27/2012) [Preconception Care for HIV Infected Women: Principles of
Preconception Care for HIV Infected Women of Childbearing Potential]
Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission.
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. Available at
http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Accessed (12/27/2012) [Pg. C-1,
Preconception Counseling and Care for HIV-Infected Women of Childbearing Age.]
Richardson, BA, Morrison, CS, Sekadde-Kigondu, C, Simei, SK, Overbaugh, J, Panteleeff, DD, et al., (1999).
Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS, 13:2091-2097
Roccio, M., et al., (2011). Low-dose combined oral contraceptive and cervicovaginal shedding of human
immunodeficiency virus. Contraception, 83:564-570.
REFERENCES
 Scholler-Gyure, M., Kakuda, T., et al. (2009). Effect of steady-state etravirine on the
pharmacokinetics and parmacodynamics of ethinylestradiol and norethindrone. Contraception, 80:
44-52.
 Squires, K., et al. (2011). Health needs of HIV-infected women in the United States: Insights from
the women living positive survey. AIDS patient care and STDs; 25(5): 1-7.
 Stringer, EM., Kaseba, C., et al. (August 2007). A randomized trial of the intrauterine contraceptive
device vs hormonal contraception in women who are infected with the human immunodeficiency
virus. American Journal of Obstetrics & Gynecology, 197(2): 144e1-8.
 Taneepanichskul, S., Tanprasertkul, C., (2001). Use of Norplant implants in the the immediate
postpartum period among asymptomatic HIV-1 positive mothers. Contraception, 64: 39-41.
 Watts, D. H., Park, J., et al. (2008). Safety and tolerability of depot medroxyprogesterone acetate
among HIV-infected women on antiretroviral therapy: ACTG A5093. Contraception, 77: 84-90.
 World Health Organization [WHO]. Medical Eligibility Criteria for Contraceptive Use. 4th ed.
Geneva, Switzerland. Accessed at:
http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf
 Zieman, M., Hatcher, R., Cwiak, C., Darney, P., Creinin, M., Sstosur, H. 2007-2009 Managing
Contraception: For your pocket. 2007. Bridging the Gap Foundation, Tiger, GA.
THANK
YOU!
Nikole Gettings, MSN, CNM
901-488-3417
[email protected]