Assessing and Supporting Reproductive
Health Care Needs and Desires of People Living with HIV
Webinar
June 22, 2016
Thank you to our Wisconsin
partners
MIDWEST AIDS TRAINING & EDUCATION CENTER
Webinar Instructions
• All attendees are in listen-only mode
• Everyone can submit questions at any time using the chat
feature
• This webinar has too many attendees for questions to be
submitted over the phone.
• During Q & A segment the moderators will read selected
questions that have been submitted.
Have a question or comment? Raise your hand, use
the question feature, or email us your questions
You may also email your
questions to
[email protected]
Disclosures
The following co-presenters have nothing to disclose:
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Barbara Cuene
Pamela Tassin
Jessica Terlikowski
Brenda Wolfe
Midwest HIV Prevention & Pregnancy Planning Initiative
(MHPPPI)
• Goal: Improve the sexual and reproductive health care of people
living with/impacted by HIV
• Provider and consumer education
• Lead organization: AIDS Foundation of Chicago
• Partners: EverThrive Illinois, Midwest AIDS Training and Education
Center, Pediatric AIDS Chicago Prevention Initiative, Planned
Parenthood of Illinois
• Priority states: IL, IN, IA, MI, MN, MO, OH, WI
• Funded by the U.S. Department of Health and Human Services
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Today’s Objectives
By the end of today’s training you will:
1. Have new strategies to meet PLHIV’s reproductive health
care needs and desires
2. Be able to initiate affirming conversations with WLHIV
about fertility desires
3. Be able to support safer conception for sero-different
couples
4. Facilitate WLHIV’s access to contraception and
conception care, resources, supports, and assistance
Women and HIV
• 23% of people living with HIV are women
• 20% of new HIV infections were in women
• Black women & Latinas disproportionately impacted
• Majority of WLHIV are of reproductive age
• Half of all U.S. pregnancies are unplanned
• Half of WLHIV learn serostatus during pregnancy
• 252,000 U.S. male-female serodifferent couples
(Neshiem et al. 2015)
Reproductive Rights
“The basic right of all couples and individuals
to decide freely and responsibly the number,
spacing and timing of their children and to
have the information and means to do so, and
the right to attain the highest standard of
sexual and reproductive health.”
--World Health Organization
PLHIV’s Reproductive Health Needs and Desires
• Access to high-quality health care through lifespan—
childbearing years and beyond
• Recognition and respect as sexual beings
• Understanding of safer conception possibilities, options,
and strategies (Kessler et al. 2010)
• Provider-initiated conversations with clinicians
“No ethical reasons” to withhold infertility
treatment from HIV-affected couple
-ASRM Committee Opinion, 2015
TDF/FTC commonly used; practice vigilance
for new HIV infections in lactating women
-ACOG, Committee Opinion 2014
HIV/Sexually transmitted diseases as a “core”
component of family planning services
-CDC MMWR, 2014
Clinical Guidelines on
PLHIV and Fertility
Pregnancy and breastfeeding are not contraindicates
to PrEP
-CDC Perinatal Guidelines, 2015
Discuss risks/benefits/alternatives of PrEP
with pregnant & breastfeeding women
-WHO, 2015
Stigma/Biases
Structural
Barriers
Inadequate
Provider-Patient
Communication
Reproductive Health Care Barriers for PLHIV
Stigma against WLHIV
“Stigma appears to be one important
factor contributing to the missed
opportunities to strategically and safely
plan pregnancies with patients and thus
preventing full application of the
science and knowledge available to
prevent new infections while
maximizing autonomy and respect for
human rights.”
(Steiner et al. 2013)
Structural Barriers to Sexual/Reproductive
Health Care for PLHIV
Sociocultural Norms
Economics
Policies
• Assumptions about who
wants/should have
children
• Men’s reproductive
desires not considered
or assessed
• Men not engaged in
preconception
conversations or care
• Majority of PLHIV are at
or below the poverty
line
• ADAP formularies
exclude contraception
• No Medicaid expansion
in 20 states, including WI
KS, & MO
• SRH attacked at state &
federal levels
• HIV criminalization laws
in 33 states, including IA,
IL, IN, KS, MI, MO, OH, &
WI
• 18% of WLHIV reported
being asked to sign a
document about “HIV
criminalization laws
related to nondisclosure,
transmission, and/or
pregnancy”
Critical Conversations are Lacking
• Sexual health conversations not occurring with many WLHIV
(Positive Women’s Network-USA 2013)
• Few providers initiate pregnancy desires conversation w/
WLHIV
• Less than 50% WLHIV desiring a baby AND a conversation had
that discussion
• Younger women asked more often than older women
(Kessler et al. 2010)
• Role of suppressed viral load in prevention not widely conveyed
(Positive Women’s Network-USA 2013)
Provider-Patient Communication Barriers
Patients
• Distrust of healthcare system
• Negative experiences with medical
community
• History of trauma
• Estimates among WLHIV:
• IPV 55%; PTSD 30%
• Feelings of judgement, stigma
Providers
• Limited time
• Limited SRH knowledge
• Discomfort managing contraception
• Lack of violence/trauma inquiry
• Believe condoms are sufficient
• Feeling topics are outside scope
• Assumption other provider is
discussing/addressing SRH issues
• Assumptions about sexual behavior
Why Provider-Initiated Conversations Matter
• Lack of conversation can be perceived as bias/disapproval
• Conception attempts may be initiated on own
• Many PLHIV are unaware it is possible to:
• Deliver HIV-negative baby
• Reduce HIV transmission between partners
• Facilitates conversation between patient and partner
• Allows for inclusion of partner in the family planning process
• Enables exploration of pregnancy ambivalence
Assessing and Supporting
Reproductive Desires
Preconception Health Care
• Not just for women planning pregnancy!
• Relevant to anyone of reproductive age,
including PLHIV
• Supports health in event of pregnancy
• Planned or unplanned
• Reduces unintended pregnancies
• Promotes awareness, responsibility and
active partner participation
• Results in better health outcomes for
parents and baby
Topics of Preconception Counseling for PLHIV
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HIV disclosure
Partner status, testing, readiness
Contraception options
Current treatment regimen
Risks and benefits of HIV drugs
Viral load levels; medication adherence
HIV impact on pregnancy; pregnancy impact on HIV
Perinatal and partner transmission prevention strategies
Pregnancy spacing
Resources available at
www.womenandhiv.org/francois-Xavier.
One Key Question
• Promotes discussion of:
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Reproductive plan or pregnancy desires
Current sexual practices
Safer conception strategies
Pre-conception care
Contraception needs/options
Adoption, surrogacy, etc.
HIV-status of partner
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Talking with Patients Who Don’t Desire Pregnancy
• Explain that pregnancy risk is 85% over year when
no contraception is used
• Inform them of the variety of methods available
• Offer guidance that reflects data available on ARV
and contraception drug interactions
• Remember that fertility desires change with
relationships and situations
• “No” now doesn’t mean “not ever”
Hormonal Contraception and WLHIV
• Most hormonal contraception is safe,
recommended
• Some ARVs may interact with contraception
• Interaction concerns SHOULD NOT preclude
prescribing patient preferred hormonal
contraception
Long-Acting Reversible Contraceptives (LARCs)
• Unknown and underutilized by many women
• Recommended as first line options
• 99% effective
• High satisfaction
• Highly recommended WLHIV
• No evidence of interaction with ARVs
• No evidence of genital tract shedding HIV
Not Your Mama’s IUD
• Safe and can be removed at any time
• IUDs containing hormone
• Mirena (5yrs)
• Skyla (3 yrs)
• Liletta (3yrs)
• Copper IUD containing no hormone
• Paragard (12 yrs)
• No reaction with ARVs
• Can be used as EC if inserted within 5 days of intercourse
Implants
• Nexplanon
• Highly effective
• Contains a progestin
• Good for three years
Shorter Acting Birth Control Method
• Depo Provera “The Shot”
• Progestin
• Quarterly injection
• May take a little longer to get pregnant once discontinued
• Conflicting observational data on link between DMPA and HIV risk
• No restrictions recommended
• CDC recommends telling HIV-vulnerable women:
• That the shot may or may not increase risk
• Use male or female condoms
Emergency Contraception
• Back-up plan if contraception
• Fails
• Is used incorrectly
• Is not used
• Doesn’t work if already pregnant
• Not harmful if already pregnant
• Some women use EC as their
contraception (this is not recommended)
The Bottom Line on Contraception
• Inform and offer range of options
• Educate about the importance of contraception for
pregnancy prevention and spacing
• Talk through what is known and unknown
• Discuss immediate insertion of LARC post abortion,
miscarriage, and delivery
• Underscore importance of dual protection-- male and
female condoms in addition to DMPA
• Let them decide what is right for them
Talking with Patients Who are Unsure
• For PLHIV: identify knowledge base or concerns
• Ask follow-up questions of patients who express uncertainty
regarding pregnancy desires:
• Do you know that PLHIV can have HIV-negative healthy babies?
• Do you intend to have children in the future?
• Do you feel now is not the right time to become pregnant?
• Do you have the resources you need?
• What resources do you need? Do you need help accessing them?
Talking with Patients Considering Pregnancy
• PLHIV can have healthy HIV-negative babies, when
• In care
• Following proper medical plan
• Pregnancy planning is the first step in decreasing
perinatal transmission
• Provide education
• Reduce anxiety
Preconception Health Care Services
Women and Men
• Discussion of reproductive life plan
• Medical history
• Sexual health assessment
• Screening and referral/treatment for:
• IPV and sexual violence
• Alcohol/drug/tobacco use
• Immunizations
• Depression
• Height, weight, BMI, blood pressure
• STDs (CT, GC, syphilis, HIV)
• Diabetes
• Hepatitis
Preparing for Healthy Pregnancy
• Check viral load
• Delay attempting pregnancy until undetectable
• Treatment suppresses HIV viral load in blood and genital fluids
• Measure CD4 count
• CD4 counts <50 can decrease ability to become pregnant
• Assess ARV regimen for safety in pregnancy
• Treat co-occurring hepatitis B infection
• Manage treatment side effects: hyperglycemia, anemia, and hepatoxicity
Preparing for Healthy Pregnancy: Partner Readiness
• Discuss preconception plan with partner and
clinicians
• Screen partner for HIV
• If partner is HIV-positive, draw viral load
• Provide necessary care/support/referrals to
achieve and maintain undetectable
• Test and treat for STIs
• Consider semen analysis for HIV-positive men
Safer Conception Strategies
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Viral suppression
PrEP/PrEP-ception
Artificial/self insemination
Timed intercourse
Assisted reproductive technologies
Viral Suppression
• Requires PLHIV consistently adhere to treatment regimen
• Necessary for optimal health of PLHIV
• Foundational step for safer conception
Artificial/Self Insemination
• WLHIV and HIV-negative partner
• Simple
• Inexpensive
• Accessible
• Increase conception chances when done during ovulation
• Use specimen cup or condom to collect sperm
• Use needleless syringe to insert semen into vagina
Timed Intercourse
• Condomless sex during peak fertility times
• Involves patient understanding and tracking ovulation
• Points to highlight with patients
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Partner must have suppressed viral load
When ovulation occurs
How to track ovulation
Where to access ovulation kits
Use of prevention method when not ovulating
PrEP-Ception
• New option for family building for sero-different couples
• HIV-negative partner takes PrEP through duration of conception
attempts
• Start daily oral doses 1 month before conception attempt
• Continue daily oral dose until 1 month after last conception attempt
• CDC clinical factsheet
www.cdc.gov/hiv/pdf/prep_gl_clinician_factsheet_pregnancy_english.pdf
PrEP-Ception
• CDC guidance recommends discussion with couples about:
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Potential risks
Adherence to daily doses
Continuing condom use after conception to reduce STI and HIV risk
Signs of acute HIV infection
Urgent need for HIV testing if HIV infection is suspected
Discuss pros and cons of staying on PrEP after conception
PEP and Pregnancy
• Option if potential HIV exposure occurs during pregnancy
• Considerations for PEP initiation same whether pregnant or not
• HIV-negative
• Started within 72 hours
• Complete 28 day regimen
• Data indicates ARVs during pregnancy don’t increase birth defects
• Enroll your patients in ARV Pregnancy Registry www.apregistry.com
• Discuss possibility of transitioning to PrEP
Clinical Guidance and Consultation
PrEPLine
855-448-7737
www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf
PEPLine
888-448-4911
Resources
• You don't have to know the answers
• You can call and get expert support 24/7
• Clinician Consultation Center
• http://nccc.ucsf.edu/clinician-consultation/perinatal-hiv-aids/
• 1.888.448.8765
• Illinois Perinatal HIV Hotline
• www.hivpregnancyhotline.org/Illinois hotline
• 1.800.439.4079
Resources
• Provider checklist and questionnaire
http://fxbcenter.org/downloads/Client_questionnaire_and_provider_checklist.pdf
• FXB Center pre-conception guides for WLHIV and providers
www.FXBcenter.org
• HIVE: A hub of positive and reproductive sexual health
www.hiveonline.org
• One Key Question
www.OneKeyQuestion.org
• 2015 Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults & Adolescents
https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0
• CDC's Medical Eligibility Criteria for Contraception Use
www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm
Wisconsin Resources
• WI HIV Primary Care Support Network
• 24 hours/day availability for support about perinatal HIV
transmission
• Call 414-266-2000 and ask for HIV Program staff on call
• Reasons for Calls:
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Pregnant woman with HIV
Pregnant woman with partner with HIV
HIV testing issues during pregnancy
Anything else related to HIV and pregnancy
WI HIV Primary Care Support Network:
Case Management Staff
• Madison –serves western WI
• Teri Meyer RN
• Solomy Ntambi Social Worker
• Milwaukee-serves eastern WI
• Vicki Decker RN,
• Wendy Simonich RN,
• Susie Gidan Social Worker
Wisconsin Data about Perinatal HIV Transmission
Progress in Reducing Perinatal HIV
Transmission in Wisconsin
19921995
Total
Total births to women
with HIV
19962005
20062015
463
59
228
225
Babies with HIV
31
13
15
4
Transmission %
6.7
22.0
6.6
1.8
Wisconsin HIV Primary Care Support Network data
In Wisconsin, Births to Women with HIV Occur Statewide
90%
80%
Percentage of Total
80%
66%
70%
60%
48%
50%
40%
52%
34%
Births inside
Milwaukee County
30%
20%
Births outside
Milwaukee County
20%
10%
0%
1992-1995
1996-2005
Year of Birth
2006-2015
Wisconsin HIV Primary Care Support Network data
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Outside Milwaukee County
Inside Milwaukee County
5
4
3
2
1
0
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Number of Children with HIV
Infection
Perinatally Acquired HIV in WI:
Cases per Year by Birth Location, 1994-2015
Year
Wisconsin HIV Primary Care Support Network data
Acknowledgements
• Cori Blum, Howard Brown Health
• Courtney Chambers, Midwest AIDS Training and
Education Center
• Barbara Schechtman, Midwest AIDS Training and Education
Center
• Anne Statton, Pediatric AIDS Chicago Prevention Initiative
• Mary Jo Hoyt, François-Xavier Bagnoud Center
• Sara Semelka, AIDS Foundation of Chicago
• Amy Johnson, AIDS Foundation of Chicago
• Danielle Pauk, Planned Parenthood of Illinois
• Vanessa Johnson, Positive Women’s Network
• Jim Pickett, AIDS Foundation of Chicago
• Naina Khana, Positive Women’s Network
• Pamela Tassin, AIDS Foundation of Chicago
• Kelly Nowicki, AIDS Foundation of Chicago
• Jessica Terlikowski, AIDS Foundation of Chicago
• Ricardo Rivero, Midwest AIDS Training and
Education Center
• Evany Turk, Positive Women’s Network
• Sheila Sanders, EverThrive Illinois
• Brenda Wolfe, Planned Parenthood Illinois
• Shannon Weber, HIVE
Have a question or comment? Raise your hand, use
the question feature, or email us your questions
You may also email your
questions to
[email protected]
Thank you!
Contact MHPPPI staff at [email protected] or (312) 922-2322.