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W orking  with  Different Groups W orking  with  Different Groups

W orking with Different Groups - PowerPoint Presentation

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W orking with Different Groups - PPT Presentation

W orking with Different Groups Module 3 e Serodiscordant Couples and PrEP PrEP and S erodiscordant Couples PrEP for HIVnegative partners offers an additional tool to reduce the risk of sexual transmission particularly if ID: 766064

couples hiv serodiscordant health hiv couples health serodiscordant partner public south pregnancy conception prevention women antiretroviral risk therapy infected

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Working with Different Groups Module 3 (e) Serodiscordant Couples and PrEP

PrEP and S erodiscordant Couples PrEP for…. HIV-negative partners offers an additional tool to reduce the risk of sexual transmission, particularly if a partner’s HIV status is unknown, or the HIV-infected partner’s plasma viral load is unknown or detectable. It is not known whether PrEP for the uninfected partner confers additional benefit when the infected partner receiving antiretroviral therapy has demonstrated sustained viral suppression. (NIH 2016)HIV-negative partners may be male or female; having anal, vaginal, or oral sex.

Promising research results

M Pleaner & N Davies (WRHI), FP/HIV Integration Meeting, Lusaka Dunkle , Lancet 2008 Homsy , PLoS ONE 2009 Kaida, AJPH 2011Beyeza-Kashesya, BMC Public Health 2010Matthews BMC Public Health 2014 Conception and HIV Stable serodiscordant couples = contribute to new HIV infections- ~30% of South Africans are in serodiscordant relationshipsHIV-affected couples want, and are having, childrenHIV-affected = serodiscordant, seroconcordant, and ‘serounknown’ couples within high HIV prevalence area Clients and providers need information about how to conceive safely within the context of HIV

Barriers Serodiscordant couples and people living with HIV: Avoid engaging in discussions about safer conception Avoidance due to embarrassmentFear of judgemental attitudes - especially related to being sexually active and desiring to get pregnantHigh rate of unintended pregnancies for women on ART62% of women on ART had an unplanned pregnancy (Schwartz et al, 2012) Healthcare providers: Healthcare providers are often more knowledgeable about preventing pregnancy (contraception), but not planning for a healthy pregnancy (conception).Healthcare providers often focus on prevention and risk, and do not have the skills to counsel on ways to get pregnant with optimal prevention for the HIV-negative partner. Harries J, et al. BMC Public Health 2007Myer, et al. AIDS Patient Care STDS 2007Cooper D, et al. AIDS Behav 2009 Schwartz, et al. PLoS ONE 2012

Policy and guidelines Southern African Clinicians Society guidelines (June 2011) Most family planning policies focus on contraception and prevention/spacing of pregnancySA revised contraception policy and guidelines include both the prevention of pregnancy (contraception) and the planning for pregnancy (conception)

HIV and safer conception – what are the options? HIV testing – need to know the status of both partners ART with viral suppressionImportant starting point for HIV-positive partner Usually about 6 months after initiationTimed peri-ovulatory intercourse or self-inseminationCondom use in betweenPrEP – added protection for the HIV-negative partnerSperm washing + IUI/IVF (available in high resource settings and private sector)Also: STI management Male medical circumcision Primary objective:Maximise chances of conceptionMinimise risk of HIV transmissionMinimise risk of mother to child transmissionCohen MS, et al. New England Journal of Medicine. 2011 Rodger A, et al. CROI 2014Anglemyer A, et al. Cochrane Database of Systematic Reviews. 2013

Optimising conception for serodiscordant couples Vaginal mucous monitoring, timed peri-ovulatory intercourse (monitoring of menstrual cycle), self insemination CFP Counselling Tool Training Oct 2016 KZN DOH (developed by WRHI/MPleaner)

PrEP and serodiscordant partners - Factors to consider Relationship complexitiesNon or partial disclosure between partners Need to engage both partners in discussions about risk and risk reductionOther issues: STIs, HIV testing, regular HIV testingIf wanting to get pregnant – need to discuss optimising conception and minimising transmission. M Pleaner & N Davies (WRHI), FP/HIV Integration Meeting, Lusaka

References Natasha Davies and Melanie Pleaner (adaptation of slides) Dunkle KL, Stephenson R, Karita E, Chomba E, Kayitenkore K, Vwalika C, Greenberg L, Allen S. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. Lancet. 2008 Jun 28;371(9631):2183-91. Homsy J, Bunnell R, Moore D, King R, Malamba S, Nakityo R, Glidden D, Tappero J, Mermin J. Reproductive Intentions and Outcomes among Women on Antiretroviral Therapy in Rural Uganda: A Prospective Cohort Study. PLoS One. 2009. http://dx.doi.org/10.1371/journal.pone.0004149 Kaida A, Laher F, Strathdee SA, Janssen PA, Money D, Hogg RS, Gray G. Childbearing intentions of HIV-positive women of reproductive age in Soweto, South Africa: the influence of expanding access to HAART in an HIV hyperendemic setting. Am J Public Health. 2011 Feb;101(2):350-8. Jolly Beyeza-Kashesya, Anna Mia Ekstrom, Frank Kaharuza, Florence Mirembe, Stella Neema, and Asli Kulane. My partner wants a child: A cross-sectional study of the determinants of the desire for children among mutually disclosed sero-discordant couples receiving care in Uganda. BMC Public Health201010:247 Matthews LT, Smit JA, Moore L, Crankshaw TL, Milford C, Mosery FN, Greener R, Psaros C, Safren SA, Bangsberg DR, Smit JA. South Africans with recent pregnancy rarely know partner’s HIV serostatus: implications for serodiscordant couples interventions. BMC Public Health201414:843

Harries J, Cooper D, Myer L, Bracken H, Zweigenthal V, Orner P. Policy maker and health care provider perspectives on reproductive decision-making amongst HIV-infected individuals in South Africa. BMC Public Health 2007, 7:282.Myer L, Morroni C, Rebe K: Prevalence and determinants of fertility intentions of HIV-infected women and men receiving antiretroviral therapy in South Africa. AIDS Patient Care STDS 2007, 21(4):278-285.Cooper D, Moodley J, Zweigenthal V, Bekker L, Shah I, Myer L: Fertility intentions and reproductive health care needs of people living with HIV in Cape Town. South Africa: Implications for integrating reproductive health and HIV care services. AIDS Behav; 2009.Schwartz SR, Rees H, Mehta S, Venter WDF, Taha TE, et al. (2012) High Incidence of Unplanned Pregnancy after Antiretroviral Therapy Initiation: Findings from a Prospective Cohort Study in South Africa. PLoS ONE 7(4): e36039. doi:10.1371/journal.pone.0036039 Rodger A, Bruun T, Valentina C, Vernazza P, Estrada V, Van Lunzen J, et al. HIV Transmission Risk Through Condomless Sex if HIV+ Partner on Suppressive ART: PARTNER Study. Conference on Retroviruses and Opportunistic Infections. 2014 Mar 3;Abstract 153LB.Anglemyer A, Rutherford GW, Horvath T, Baggaley RC, Egger M, Siegfried N. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database of Systematic Reviews. 2013;4:CD009153.Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011 Aug 11;365(6):493–505. NIH. 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 (14/11/2016)

Acknowledgements With thanks to: The Southern African HIV Clinicians SocietyWits Reproductive Health and HIV Institute (Natasha Davies, Melanie Pleaner)