Reproductive Health and HIV: Preconception Care, Family planning & Safer conception

1. Welcome! The Webinar will being in just a few minutes. Please remember to turn on your computer speakers and adjust speaker volume. Reproductive Health and HIV: Preconception Care, Family planning & Safer conception

2. 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.

3. Webinar schedule • Session 1: Preconception Care in the Setting of HIV Infection • Session 2: Contraceptive care for women/couples living with HIV infection • Session 3: Safer conception for HIV-discordant couples

4. Navigating the Webinar • Three short videos will be shown during the webinar • Please close other applications on your computer • At times during the webinar, we will ask poll questions • A separate window will show the questions • Choose your response • Responses will be displayed after you vote • Please type your questions or comments for the speakers in the chat box at the bottom right of your screen.

5. Materials and Evaluation Participants will receive and e-mail with links to the webinar recording, slide set, support tools and evaluation survey The link for the evaluation survey is available in the chat box If you did not register for this event, please send your name and e-mail address to phillijm@umdnj.edu

6. 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

7. 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 HIV-infected men. • Describe preconception assessment and interventions for women living with HIV.

8. Module objectives • Explain the role of the HIV primary care provider in preconception counseling and care • Discuss models of integration of preconception care

9. Case study • Gloria is a 32 year old HIV+ AA female • HIV acquired from a previous boyfriend • No significant medical history/on no medication • CD4 380 and viral load is 24,000 • She is returning for her 2nd visit to discuss ART Role Play

10. Poll

11. amfAR, n=4831 US adultsemail survey (2008)

12. 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

13. 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

14. Fertility desires and intentions

15. Contraceptive Use Among US Women with HIV Women's Interagency HIV Study (WIHS): In over 30% of these visits, HIV-infected women reported not using any form of contraception. Massad et al. (2007) J Women’s Health

16. Estimated # of births to women with HIV Fleming (2002) Office of Inspector General Whitmore, et al. (2009) CROI

17. 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 HIV- women 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

18. 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

19. 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 ACOGPractice Bulletin No 117; December, 2010

20. Importance of preconception care • Women and menliving 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

22. Unintended pregnancy Finer and Henshaw (2006) Perspec Sex Repro Health; Massad (2004) AIDS Koenig (2007) AJOG ; Floridia (2006) AntivirTher

23. 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)

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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 HIV-related medications • Disclosure of HIV diagnosis • Partner testing • Safer conception options

30. Conduct preconception counseling • Address alcohol, drugs and/or tobacco use • Recommend avoidance of OTCs • Consider delaying pregnancy until health is optimized

31. Optimize preconception health Screen for: • Syphilis Refer for: • Genetic screening, based on history • Contraception, as needed, to delay pregnancy while health issues are addressed Provide: • Folic acid 400 mcg daily • Immunizations, as needed, for: • hepatitis B • rubella • varicella

32. 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

33. 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 potentialduring the preconception period.

34. How can preconception care be integrated into the HIV primary care setting?

35. 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

36. 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

37. 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

38. 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

39. Integrating preconception and HIV care • An informational brochure for clients on preconception health and the importance of preconception care

42. Integrating preconception and HIV care • Guide to preconception counseling for the HIV care provider

43. Questions and Comments* *Type in the chat box and then click “Enter”

44. Contraceptive Care for Women with HIV Infection and their Partners Kimberly McClellan, MSN, WHNP-BC, CRNP Director Women's Health AIDS Care Group, Chester PA ksv23@drexel.edu

45. Objectives • Describe considerations for selecting appropriate contraceptive and compare options for women living with HIV • Explain specific consideration related to hormonal contraception and antiretroviral treatment • Identify issue related to hormonal contraception and HIV progression, transmission or acquisition

46. Case study One year later: • Gloria initiated ATV/r + TDF/FTC combination therapy and has achieved viral suppression with CD4 count of 500 • She is here for a routine visit and is doing well Role Play

47. Poll

48. Benefits of Contraception for HIV-Positive Women • Prevents unintended pregnancy • Half of all pregnancies in U.S. are unintended • Allows women to plan a pregnancy that • Is well timed • Occurs in optimal health • Minimizes risks for perinatal transmission

49. Special Considerations Regarding HIV and Contraception • Potential drug interaction with antiretrovirals (ARVs) • Possible effects on HIV transmission • Possible effects on HIV acquisition • Possible effects on HIV progression

50. Typical Effectiveness of Contraception HIV-positive women generally have the same options as uninfected women