Reproductive Health and Preconception Care of HIV-Infected Women

1
Reproductive Health and Preconception Care of
HIV-Infected Women

• Development Implementation of National
  Recommendations

2
Disclosure

• With support from the
• Centers for Disease Control and Prevention
• The findings and conclusions in this presentation
  are those of the authors and do not necessarily
  represent the views of the Centers for Disease
  Control and Prevention.

3
Objectives

• To briefly describe the importance of caring for
  the reproductive health of HIV-infected women in
  the US.
• To describe the process of developing
  national-level recommendations to improve the
  reproductive health of HIV-infected women.
• List selected recommendations made by the Expert
  Panel on Reproductive Health and Preconception
  Care of HIV-infected Women.
• To discuss progress toward implementing these
  recommendations to date.

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Preconception Care of HIV-infected Women (1)

• Reproductive health needs not being met
• Separation of GYN and HIV care
• Preconception counseling and care not being
  addressed pro-actively
• Reproductive health care often not a priority for
  patients or providers

5
Preconception Care of HIV-infected Women (2)

• With improved survival and health and decreased
  risk of MTCT, many HIV women are choosing to
  conceive
• Effective contraceptive is underused unplanned
  pregnancies are common
• Women face barriers related to stigma, safe
  conception with serodiscordant partners, and
  other issues

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Preconception Care of HIV-infected Women
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Chain of Events Leading to an HIV-infected Child

• The proportion of women . . .
• ? Who are HIV-infected
• ? Who become pregnant
• ? Who do not seek prenatal care
• ? Who are not offered HIV testing
• ? Who refuse testing
• ? Who are not offered ARV prophylaxis
• ? Who refuse ARV prophylaxis
• ? Who do not complete ARV prophylaxis
• ? Whose infant does not receive ARV
  
  prophylaxis
• ? Whose child is infected despite
  prophylaxis

Adapted from IOM, 1998
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Steps to Reducing Perinatal HIV Transmission

• ? Primary HIV prevention in women
• ? Comprehensive preconception/interconception
  care
• ? Prevention of unintended pregnancy in HIV
  women
• ? Accessible, affordable, welcoming prenatal
  care
• ? Universal prenatal HIV testing, including
  3rd trimester repeat testing in areas of
  high-incidence
• ? Re-offering testing to those who
  initially decline
• ? Offer ARV treatment/prophylaxis to all
  HIV-infected women
• ? Adherence support for ARVs
• ? Rapid test for women with
  undocumented HIV status in labor
• ? ARV prophylaxis for women
  identified in labor
• ? ARV prophylaxis of all
  HIV-exposed newborns
• ? Comprehensive services for mother and
  infant

Were working on it!
FXB Center UMDNJ, 2002, 2009
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Estimated number of births to women living with
HIV infection, 2000-2006
2006 estimate (8,650 8900) is 30 gt 2000
estimate (6075 6422)
Office of Inspector General (Fleming), 2002
Whitmore, et al. CROI, 2009
10
Live Births Among HIV Women Before and After
HAART Availability Sharma, et al. AJOG 2007

• Comparison of live birth rates 1994-1995
  (pre-HAART era) and 2001-2002 (HAART era) in HIV
  and HIV- women 15-44 yrs
• In HAART era 150 increase in live birth rate
  among HIV women vs. 5 increase among HIV- women

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Clinicians Fail to Routinely Provide Reproductive
Counseling to HIV-Infected Women in the US
(Averitt Bridge et al. 2008)

• Women Living Positive Survey
• Interviewed 700 HIV women
• 31 were contemplating pregnancy or had been
  pregnant
• 48 were not asked by their HIV provider if they
  wanted to have a child
• Of women who had thought about pregnancy or who
  were pregnant
• 41 had not discussed HIV treatment change in
  event of pregnancy
• 29 said their HIV provider did not explain the
  effects of HIV medication on them or their baby

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Contraceptive Use Among US Women with HIV(Massad
et al. J Womens Health 2007)
13
Cumulative Incidence of First Pregnancy in 174
Perinatally HIV-Infected Sexually Active Girls
Age gt13 Years, PACTG 219CBrogly SB et al. Am J
Public Health 2007
Screen for pregnancy in HIV-infected Adolescents!
By age 19 years, 24.2 of sexually active girls
had been pregnant at least once (6 had 2nd
pregnancy, 1 had 3rd)
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Background of Recommendations

• Spring 2008
• Key informant interviews
• Literature review
• Key topics, process, invitees identifed
• July 2008
• Expert Panel sponsored by CDC/FXB
• 32 participants governmental, academic and
  community representatives

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The Meeting

• Presentations laid groundwork
• Facilitated small group work
• Development of national recommendations with
  action steps
• Integrate RH and HIV care
• Primary HIV prevention
• Large group report back with discussion
• One Wish
• Buy-in for ongoing process

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After the Meeting

• Recommendations prioritized
• High/low impact and resources
• Expert Panel ongoing planning calls
• Publication and dissemination of recommendations
• AIDS - Journal of the International AIDS Society
• APHA 2009
• AIDS Alliance Voices 2010
• ANAC 2008 2010

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Policy Recommendations

• Integrate adult and perinatal US treatment
  guidelines on preconception care
• Organize talking-points about data needs and
  present to stakeholders in funding research
• Advocate to CMS for reimbursement of services
• Advocate for Ryan White to include additional
  funding for women
• Include Title X grantees to improve linkages
• Co-locate clinics
• Conduct Special Project of National Significance
  (SPNS) projects to demonstrate integration of
  Title X and Ryan White care providers and
  services
• Collaborate with ACOG on defining preconception
  care in context of HIV infection

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Program/Services Recommendations

• Assemble and disseminate best practices that link
  Title X agencies and Ryan White agencies
• Add a HRSA quality indicator on preconception
  care
• Develop trainings for HIV providers that increase
  comfort and knowledge about HIV and pregnancy
• Hold joint trainings for HIV and Title X
  providers
• Advocate to the AETCs to increase their focus on
  womens health
• Develop tools for busy HIV providers to
  streamline preconception care and counseling
• Create mentoring program for new HIV providers

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Research/Data Recommendations

• Perform a fishing expedition of existing data
• Perform research that will address the following
  gaps in data
• of HIV-infected women who deliver per year?
• of HIV-infected women who get pregnant each
  year?
• How many of these pregnancies are repeat
  pregnancies?
• Conduct studies on
• the efficacy of hormonal contraception for
  HIV-infected women
• the effectiveness of reproductive health
  technologies for HIV-infected women on HAART
• Pre- exposure prophylaxis (PrEP) for discordant
  couples

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Progress on Recommendations (1)

• Integration of adult and perinatal guidelines
• Joined forces with like-minded advocates to write
  AIDS correspondence piece
• Joint training for family planning and HIV
  providers
• ACOG survey
• Perinatal HIV screening practices
• Routine HIV screening practices
• Useful preconception care tools

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Progress on Recommendations (2)

• Publication and promotion of recommendations
  include Title X and HIV experts
• Preconception care and counseling tool
• CDC Institute on perinatal prevention, including
  preconception care, at Ryan White All-Grantees
  meeting in 2010

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Progress on Recommendations (3)

• Preconception care incorporated into CDCs
  national framework for perinatal elimination
• Letter to Office of National AIDS Policy
• Ongoing work of the perinatal elimination
  stakeholders group

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Conclusions

• Assuring the reproductive health for HIV-infected
  women in the US is a means to an end the end
  being comprehensive care for women and progress
  toward the elimination of HIV-infection in
  children.
• The assembly of experts and ongoing working
  groups are a mechanism to forward changes to both
  clinical care and HIV policy in the US.

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Thank You

• To Dr. Jean Anderson for many of her slides for
  this presentation
• To the members of the CDC/FXB Expert Panel