Family Planning for Persons Living with HIVAIDS Nikole D Gettings BS RN MSN CNM APN Activity Planning Committee Medical Review Committee Donna Randolph MD CHOICES Medical Director ID: 734828
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Slide1
Reproductive Choice and Family Planning for Persons Living with HIV/AIDS
Nikole D. Gettings, BS, RN, MSN, CNM, APN Slide2
Activity Planning CommitteeMedical Review Committee
Donna Randolph, MD, CHOICES Medical DirectorBev Byrum, MSN, NP, Adjunct Faculty, Vanderbilt School of NursingNikole Gettings, MSN, CNM, CHOICES Clinic Services DirectorPatricia 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, CIDCVictoria Harris, Ed.D. Director of Education, TN AIDS Education & Training Center, Vanderbilt Comprehensive Care ClinicProject Administrative Coordination:Lanita Williams, MPH, ARHP Program Manager
Katherine Leopard, CHOICES Community Partners CoordinatorJennifer Pepper, CHOICES Assistant DirectorSlide3
www.memphischoices.org Slide4
Why Parallel Paths?
Women have sexual and reproductive health needs related to HIV testing and prevention
Routine HIV Testing
Prevention Counseling
Linkages to HIV Care, if Infected
Women Living with HIV have sexual and reproductive health needs
Pregnancy Prevention
Pregnancy Planning
Basic GYN Care
STI Testing and Treatment
Prenatal Care
Abortion
Horton, Gettings, and Marshall, (2009).Slide5
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.Explain to patients the most effective contraception options and the specific drug interaction between HAART and hormonal birth control methods.Provide counseling tips regarding pregnancy options for persons living with HIV in a non-directive way including healthy preconception practices.Identify local and national resources for reproductive health care for persons living with HIV.Slide6
HIV Statistics (2007)Slide7
McGowan, Pepper, Gettings, Capece and Rinsdale, 2014Slide8
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 pregnanciesSlide9
Case Study # 2:
When are you planning a pregnancy?Kayla
PMHMedications
Family History
Social History
Sexual Health HistorySlide10
Developing a Reproductive Life Plan: Pregnancy PlanningWhen 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 2014Slide11
Developing a Reproductive Life Plan: Pregnancy PreventionHow 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 2014Slide12
Developing a Reproductive Life Plan: Patient Decision Factors
CostSide effectsDelivery MethodControlHow long will it work Effectiveness
MMWR June 2013; MMWR April 2014Slide13
Developing a Reproductive Life Plan: Clinician Decision FactorsFertility Desire
Medical History and co-morbiditiesAgeSmoking StatusAccess to healthcareAdherence to healthcareDecision making abilityMMWR June 2013; MMWR April 2014Slide14
Categorizing Contraception Pill
PatchRingMedroxyprogesteroneLevonogestral Intrauterine DeviceWithdrawalSpermicideCondom (Male and Female)Copper Intrauterine DeviceSterilizationMale Female
Hormonal
Non HormonalSlide15
Categorizing Contraception
Short ActingLong ActingWithdrawal
SpermicideCondoms (Male and Female)PillsPatchRingMedroxyprogesterone
Levonogestral Intrauterine Device
Copper Intra Uterine Device
Sterilization
Male
FemaleSlide16
WHO Eligibility Criteria for Starting ContraceptionWHO 1
: Can use the method. No restrictions to useWHO 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.Slide17
Quality of EvidenceI: 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 ForceSlide18
Quality of Recommendations based on researchLevel A: Recommendations are based on good and consistent scientific evidence
Level B: Recommendations are based on limited or inconsistent scientific evidenceLevel C: Recommendations are based primarily on consensus and expert opinion.
American College of Obstetricians and Gynecologists, 2010Slide19
GuidelinesCDC: MMWR
American College of Obstetricians and GynecologistsU.S. Selected Practice Recommendations for Contraceptive Use, 2013 Vol. 62, No. 5; June 21, 2013Providing Quality Family Planning Services: Recommendations of the CDC and the U.S. Office of Population Affairs, Vol. 63, No. 4; April 25 2014ACOG: 2010Practice Bulletin No. 117, Dec. 2010The care of HIV-infected WomanSlide20
Contraception and HIV: Special FactorsPregnancy Prevention Effectiveness
Risk of HIV infection acquisitionRisk of HIV progressionRisk of increase viral load of HIVRisk of decrease CD-4 countRisk of infectious complicationsAdditional risk of STI vulnerabilityRisk of overall complicationsRisk of increased transmission rate of HIV to partner(s)
ACOG, 2010; Ezeanolue, et al., 2011Slide21
LARC: Intrauterine Devices (IUDs)WHO Category 2
No difference in complications between HIV+, clinically well, and HIV- womenHigher rate of efficacy than combined oral contraceptivesNo adverse effects on CD4 countNo association between IUD and HIV transmission: No increased genital shedding of HIV RNAWomen with advanced immunosuppression: WHO 3, monitor closely for signs of infection
Kapiga 1998, Morrison 2001; Heikinheimo, et al. 2006; Richardson et al, 1999Slide22Slide23
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: 2/3Limited studies show no known drug interactions for women on HAARTNo increase in HIV RNA genital sheddingNo decrease in CD4
Lehtovirta, P, et al., 2007; Heikinheimo, et al., 2006Slide24
IUD Patient Counseling Pearls: Copper IUD (ParaGard)
Primary mechanism is copper ion effects on sperm1-10 yearCost effectiveNo Hormonal Side EffectsMenstrual bleedingOngoing Evaluation: Annual or symptom based
Hatcher, et al.,
Contraceptive Technology, 2007
.Slide25
IUD Patient Counseling Pearls: Levonogestrel Intra-Uterine System
Primary mechanism: thickens cervical discharge to inhibit sperm mobilitySecondary mechanism: ovulation inhibition and resultant endometrial thinning1-5 yearsCost effectiveHormonal Side EffectsBleeding PatternEvaluation: Annual or symptom based
Hatcher, et al.,
Contraceptive Technology, 2007Slide26
LARC: Levonorgestrel
– Implant (Nexplanon/Implanon)WHO Category: 1Specific Studies are very limitedSimilarities to other hormonal methods
Fakoya 2008Slide27
Levonorgestrel Implant: Patient Counseling Pearls
Primary mechanism: thickens cervical discharge to inhibit sperm mobilitySecondary mechanism: ovulation inhibition and resultant endometrial thinningMay be used for 1-3 yearsProvider TrainingImplantation: Needle Removal: small incision Bleeding patternOther hormonal side effects; scarring with insertion or removalEvaluation: Redness, persistent pain at site of insertion
Hatcher, et al., (2007)
, Contraceptive Technology; Slide28
LARC: Medroxyprogesterone acetate (Depo Provera)
WHO Category: 1No risk of HIV disease progressionNo adverse effects on CD4 count or viral loadInconsistent results regarding hormonal contraceptive and increased risk of HIV-1 DNA or RNA shedding from genital tract.Weight Gain/LossBone Mineral DensityFat Re-DistributionMinimal to no drug interactions
Watts 2008, Yin 2005, Brown 2007Slide29
Medroxyprogesterone Acetate: Patient Counseling Pearls
Primary Mechanism of Action: Primary mechanism: thickens cervical discharge to inhibit sperm mobilitySecondary mechanism: ovulation inhibition and resultant endometrial thinning3 month intervals (13 weeks)Delivery method: Shot, unable to remove once administeredCost EffectiveHormonal Side EffectsBleeding PatternOther Side Effects: Headaches, depressionWeight Calcium Supplementation
Hatcher et al.,
Contraceptive Technology, 2007; Watts, et al., 2008Slide30
Short Acting Hormonal Methods: The Pill, Patch, and Ring
WHO Category 1Attention to drug interactions with HAART and ARVRisk 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; Slide31
Hormonal Short Acting Counseling PearlsPrimary mechanism: thickens cervical discharge to inhibit sperm mobility
Secondary mechanism: ovulation inhibition and resultant endometrial thinningDelivery Method: Patient controlled daily, weekly or monthlyEffectiveness: Compared to other methodsBleeding PatternsOther Side EffectsDrug Interactions
Hatcher, et al., (2007)
, Contraceptive TechnologySlide32
Emergency ContraceptionInteractions with ART have not been studied
British recommendations: double-doseCopper IUD placementEspecially for women who present 4-5 days after intercourse
Stewart 2007, Fakoya 2008Slide33
Contraception and HIV: Drug InteractionsIncreased steroid dosage (contraception)
P450 MetabolismIncreased ART medication dosageDecrease steroid dosage (contraception)Decrease ART Medication dosageComplicated interactions Adverse side effectsACOG, 2010; WHO, 2010Slide34
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 togetherBirth 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, 2010Slide35
Contraception and HIV: General Drug Interactions SummaryContraception Hormonal MetabolismRitonavir-Boosted Protease Inhibitors: Decrease hormonal contraceptive efficacy
Non-Nucleoside Reverse Inhibitor: Contraceptive Efficacy may be affected:NevirapineAtazanavir or indinavirEfavirenzAnti-Retro Viral EffectsRitonavir: Liver transaminasesTipranavir/Ritonavir: Increased skin and musculoskelatal adverse events; possible increased drug hypersensitivitySlide36
Drug Interactions to Consider
Studies are limited and type specificAptivus® (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
, 2010Slide37
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?Slide38
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 CSlide39
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) CondomsSlide40
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) CondomsSlide41
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 aboveSlide42
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/AbuseSlide43
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?Slide44
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 Exampleshttp://dhss.delaware.gov/dph/chca/files/adultlifeplan2011.pdfhttp://everywomannc.com/sites/default/files/documents/Are%20You%20Ready%20-%20Sex%20And%20Your%20Future.pdf
http://famplan.org/Resources/Docs/adult_rhp_busy_woman.pdfhttp://famplan.org/Resources/Docs/teen_rlp.pdfSlide45
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) : 1492-1509.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, 2
nd
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.Slide46
ReferencesEzeanolou
, 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.Slide47
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-infected-women/. 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, 13:2091-2097Roccio
, M., et al., (2011). Low-dose combined oral contraceptive and
cervicovaginal
shedding of human immunodeficiency virus.
Contraception, 83
:564-570.Slide48
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.pdfZieman, 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.Slide49
THANK YOU!
Nikole Gettings, MSN, CNM901-488-3417ngettings@memphischoices.orgSlide50
[Procreation] is central to personal identity, to dignity and to the meaning of one’s life
~ Robertson (1994)Slide51
Preconception Counseling for Women Living with HIV
Ideal for ALL women of childbearing ageShould include discussion of the following:Method of becoming pregnantMaternal healthReducing the risk of transmission to babyManagement of baby exposed to ARVMonitoring for infant to determine HIV statusManagement if baby is HIV+
Child guardian if parent becomes ill or diesHow and when to disclose HIV+ status to child
DHHS 2008; ACOG 2010; Aaron & Criniti 2007Slide52
Preconception CounselingAmerican College of Obstetricians and Gynecology [ ACOG]
American Society for Reproductive Medicine [ASRM]Center for Disease Control [CDC]Slide53
Physicians encouraged to advise HIV positive women to defer pregnancy because of poor outcomes associated with pregnancy and childbirth while positivePhysicians are instructed to inform HIV positive clients about all their reproductive options with counseling that is non-directive and supportive of client’s decision
Centers for Disease Control
1985
2001Slide54
All individuals seeking fertility assistance should be tested for HIVIf individual is HIV +, couple should be counseled on donor sperm, adoption, or not having children.
HIV is a chronic, manageable disease and expected life span can be near normalIf individual is HIV +, couple should be counseled on ways to plan a pregnancy while significantly decreasing risk of HIV transmission to HIV – partner and/or child(ren).The Ethics Committee of the American Society for Reproductive Medicine
The Ethics Committee of the American Society for Reproductive Medicine (June 2010). Fertility and Sterility, Vol. 94, No. 1, 11-15.
1994
June 2010Slide55
Women seeking pregnancy should weigh her desire for childbearing against the potential harm to an infected childPhysicians should weigh the moral appropriateness of any medical treatment
Physicians should be prepared to have detailed discussions about how to plan a pregnancy to avoid HIV transmissionArtificial insemination, although not guaranteed to have no risk, is endorsed as a way to avoid transmissionAmerican college of Obstetricians and gynegologists [acog]
1993
December 2012Slide56
Teaching: Role of PrEPTruvada Daily: 300 mg/200 mgHepatitis B Vaccine/evaluate immunity
HIV Negative confirmedRoutine access to healthcare provider and health resources for ongoing evaluationCreatinine Clearance >60 ml per minuteHIV evaluation q 3 monthsSTI evaluation and treatment as indicatedPregnancySafety to continue PrEP during pregnancy
World Health Organization, (July 2012); Centers for Disease Control (August 2012).