Preconception Counseling and Education for HIV-Infected Women
description
Transcript of Preconception Counseling and Education for HIV-Infected Women
Learning ObjectivesDescribe perinatal HIV transmission: past and
presentExplain the rationale for preconception counselingIdentify barriers and challenges to preconception
counselingDefine overall preconception health goalsDescribe benefits of perinatal counselingDescribe childbearing desires and intentionsReview current recommendations for preconception
care to prevent perinatal HIV transmission
DefinitionsPerinatal HIV transmission: “Transmission of HIV
from mother to child during pregnancy, labor and delivery, or breastfeeding…”
Preconception Counseling: “Interventions that aim to identify and modify biomedical, behavioral and social risks to a women’s health or pregnancy outcomes through prevention and management.”
CDC, 2007; CDC, 2006
Women Living With HIVBetween 120,000 – 160,000 women in U.S.
currently infectedOne quarter unawareMost infections acquired heterosexuallySignificant racial disparities
57% black, 1 in 32 lifetime risk14% of all HIV, 66 percent of AIDSWorse in the South: up to 75% of AIDS
16% Hispanic/Latina, 1 in 106 lifetime risk
About 6000 women with HIV are giving birth each year
CDC, 2011
Perinatal transmission of HIV: Past and Present1994: Study demonstrated Zidovudine (ZDV) reduced
mother-to-child transmission (MTCT) risk by about 70%Testing for HIV now routine in pregnancy and so is
routine use of antiretroviral treatmentEffective combination HAART regimens: MTCT in
fewer than 2 in 100 births95% decrease in pediatric MTCT HIV between 1992 –
2005Without treatment and with breastfeeding: about 25%-
30% transmission risk
Burr et al., 2007; CDC, 2011
Remaining Perinatal Transmission Challenges 100 – 200 infants infected annually in the U.S.
Remains the most common route of HIV infection in children Almost exclusive source of all AIDS cases in children Most with AIDS are of minority races/ethnicities
Why? Some practitioners continue to test only women considered “high risk” Lack of re-testing late in pregnancy to identify women who sero-converted since
initial screen Some mothers and babies still do not receive appropriate antiretroviral (ARV)
treatment and prophylaxis Healthcare services are not accessed: lack of preconception
counseling/education/lack of prenatal care
CDC, 2007; Fowler et al., 2007
HIV Sero-discordanceHIV sero-discordance: One partner has HIV, the other partner
is uninfectedEstimated 140,000 heterosexual couples who are sero-
discordant in the U.S.Estimated half want to conceive at some point
Significant number are probably having unprotected sex to achieve conception
Between 20 to 80 percent of newly diagnosed HIV-positive pregnant women may have uninfected partners
There is decreased rate of transmission when viral load fully suppressedTreatment of infected partner does not guarantee
transmission will not occurRisks and fertility recommendations specific to which
partner has HIV
Hoyt et al., 2012; Strong, 2003
Perspective of HIV-infectedwomen From “Women Living Positively Survey”
Telephone-based survey of 700 women with HIV, across U.S.: Mostly minority 55%: no discussion of gender-based treatment 43%: had switched providers because of
communication issues 57% (had been or were currently pregnant): no
discussion of pregnancy and treatment options prior to becoming pregnant
42%: not aware at all or not very aware of treatment options
Little to describe how effectively providers address preconception needs
Significant communication gaps
Squires et al., 2011
Recommendations from the Women Living Positively SurveyGender-specific discussions should be
included in each visitPut knowledge of those differences into
practiceMay need to offer training, including
communication techniquesNeed to establish an environment conducive to
open communicationEncourage discussion on treatment,
psychosocial and emotional aspects of care
Squires et al., 2011
Childbearing desires and intentions “Fertility Desires and Intentions of HIV-Positive Men
and Women”Interviews with 1,421 HIV-infected adults in 199828-29% of HIV-infected men and women desired to
have children 69% of women and 59% of men who desired children
expected to have at least one child in the future
Desire for future childbearing was not related to measures of HIV progression
Chen et al., 2001
Childbearing Desires and Intentions“Understanding High Fertility Desires and Intentions
Among a Sample of Urban Women Living with HIV in the United States”Fertility desires 59% Childbearing Intentions 66% (of those desiring a child)Accurate knowledge of MTCT was low (15%)
Unmet need for counseling on reproductive decisions/safe childbearing
“In the absence of open discussion regarding reproductive plans and options for safe conception, women confused about how to protect their partner and achieve pregnancy may likely leave it to chance.”
Finocharrio-Kessler et al., 2010
Childbearing desires and intentions“Discussing Childbearing with HIV-infected Women of
Reproductive Age in Clinical Care: A Comparison of Brazil and
the US”
Finocchario-Kessler et al., 2012
Unintended Pregnancies“High prevalence of unintended pregnancies in HIV-positive
women of reproductive age in Ontario, Canada: a retrospective study”
56% HIV infected women surveyed stated their last pregnancy was unintended (n=416) Marital status and never having given birth were significantly
associated with unintended pregnancy
Loutfy et al., 2012
Overall Preconception Health GoalsImprove preconception care-related knowledge,
attitudes, and behaviors of men and womenAssure ALL women receive preconception care
services so they may enter pregnancy in optimal health
Reduce risks during inter-conception period Reduce disparities associated with adverse
pregnancy outcomes
CDC, 2012
Rationale for HIV-Related Preconception CareAdvances in prevention of transmission and care of those
infectedFamily planning desires and intentionsUnintended pregnanciesUnmet needs for discussing personal and specific
reproductive plansSerodiscordancePotentially enhance fertility through optimal use of ARVOptimize maternal and infant outcomes
Hoyt et al., 2012
Potential Barriers/Challenges
Providers may be unsure how to bring up family planning or what to sayRisk of transmission still exists
Different degrees of risk of HIV transmission Depend on HIV concordance/discordance, fertility methods, health status, viral
load, etc.Assumption that children are not desired
Political resistance, differing ideological viewsPrevention of unintended pregnancies in women with HIV often remains secondary to other
HIV care prioritiesUndefined clinician roles
Kemper, 2008; Strong, 2003; Hoyt et al., 2012
Potential Barriers/ChallengesProviders may…
Feel justified in reducing risk by offering “safer” options
OR
Feel complicit due to risk of vertical or horizontal transmission
Potential Barriers/ChallengesWoman may not seek care or counseling, to avoid
discriminatory or disrespectful treatment, even from health provider
May feel under close scrutiny during pregnancyPressure to meet expectations: family, friends, partnerCriticism and questions about taking medications
Antenatal classes, unless specialized, may not meet needs of HIV-infected pregnant women Commonly focus on vaginal delivery and
breastfeeding
Hawkins et al., 2005
What are the Benefits of Providing Preconception Counseling?
Meet reproductive needs of HIV-infected women and their partners
Address fertility desires and intentions of those living with HIV
Educate and inform of the safest fertility options for HIV-concordant and HIV-discordant couples
Optimize maternal and fetal health
Hoyt et al., 2012
What are the Benefits of Providing Preconception Counseling?Protects the rights and health of those living with HIVPrevent unintended pregnancies in HIV-infected clientsPrevent perinatal transmission of HIVProvide family-centered care
Stronger connection between HIV services and sexual and reproductive health
Hoyt et al., 2012
HIV and the “Right” to ReproduceReproductive and sexual rights are human rights, protected
under international conventionsHIV is covered in the Americans With Disabilities Act (ADA)
under “disability” and “health status”Failure to uphold and protect human rights is considered
discriminationHIV-related discrimination reduces the likelihood women
will obtain needed health servicesPreconception counseling and information should be
available and provided on preventing perinatal HIV transmission and optimizing maternal and infant health
Gable et al., 2008
Current Recommendations Discuss childbearing intentions with all women of childbearing age on an
ongoing basis throughout the course of their care. Include information about effective and appropriate contraceptive methods to
reduce the likelihood of unintended pregnancy. During preconception counseling, include information on safer sexual
practices and elimination of alcohol, illicit drugs, and smoking, which are important for the health of all women as well as for fetal/infant health, should pregnancy occur.
When evaluating HIV-infected women, include assessment of HIV disease status and need for antiretroviral therapy (ART) for their own health.
Choose an ART regimen for HIV-infected women of childbearing age based on consideration of effectiveness for treatment of maternal disease, hepatitis B virus disease status, teratogenic potential of the drugs in the regimen should pregnancy occur, and possible adverse outcomes for mother and fetus.
Source: 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, http://aidsinfo.nih.gov/contentfiles/lvguidelines/perinatalgl.pdf, Updated July, 2012
Current RecommendationsPreconception care should be addressed as a
process of ongoing care and not as a single visitComprehensive family planning and preconception
care should be integrated into routine careProviders should initiate these non-judgmental
conversations becauseAlmost 50% of pregnancies are unintendedPatients may be reluctant or afraid to bring it up
Source: 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, http://aidsinfo.nih.gov/contentfiles/lvguidelines/perinatalgl.pdf, Updated July, 2012
http://fxbcenter.org/downloads/Counseling_Tool_HIV_Preconception_Care.pdf
http://fxbcenter.org/downloads/Counseling_Tool_HIV_Preconception_Care.pdf
Final Thoughts If providers do not /implement promote preconception counseling and
education, the need will not disappear…it will simply remain unaddressed Barriers and stigma still exist for those with HIV who want to have a family Women and men living with HIV are no different in their desires to have
children. Many women living with HIV have unplanned pregnancies. Effective preconception education and counseling helps to:
Provide the best chance for good health and outcomes for those living with HIV and their infants
Meet family planning and reproductive needs of those living with HIV Educate those living with HIV on the safest and most effective
reproductive options for childbearing, prevention of HIV transmission, and pregnancy prevention
Gable et al., 2008; FXB Center, 2012; Hoyt et al., 2012 ,
Questions?
Thank You!
References AIDSinfo (2012). 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. Retrieved from http://aidsinfo.nih.gov/guidelines
Centers for Disease Control and Prevention (2006). Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR 2006; 55(No. RR-14): 1-17.
Centers for Disease Control and Prevention (2011). HIV among women. Retrieved from http://www.cdc.gov/hiv/topics/women/index.htm
Centers for Disease Control and Prevention (2012). HIV/AIDS statistics and surveillance.
References Finocchario-Kessler, S., Bastos, F. I., Malta, M., Anderson, J., Goggin, K.,
Sweat, M., ... & Kerrigan, D. (2012). Discussing childbearing with HIV-infected women of reproductive age in clinical care: a comparison of Brazil and the US. AIDS and Behavior, 16(1), 99-107.
Fowler, M. G., Lampe, M. A., Jamieson, D. J., Kourtis, A. P., & Rogers, M. F. (2007). Reducing the risk of mother-to-child human immunodeficiency virus transmission: past successes, current progress and challenges, and future directions. American journal of obstetrics and gynecology, 197(3), S3-S9.
FXB Center (2012). The HIV and Preconception Care Toolkit. Retrieved from http://fxbcenter.org/downloads/Counseling_Tool_HIV_Preconception_Care.pdf
Gable, L., Gostin, L. O., & Hodge Jr, J. G. (2008). HIV/AIDS, Reproductive and Sexual Health, and the Law. American Journal Of Public Health, 98(10), 1779-1786.
References Hawkins, D. D., Blott, M. M., Clayden, P. P., De Ruiter, A. A., Foster, G. G.,
Gilling-Smith, C. C., & ... Taylor, G. G. (2005). Guidelines for the management of HIV infection in pregnant women and the
prevention of mother-to-child transmission of HIV. HIV Medicine, 6(s2), 107-148. doi:10.1111/j.1468-1293.2005.00302.x
Hoyt, M. J., Storm, D. S., Aaron, E., & Anderson, J. (2012). Preconception and contraceptive care for women living with HIV. Infectious
Diseases in Obstetrics and Gynecology. doi: 10.1155/2012/604183. Kemper, C. A. (2008). Pregnancy Counseling in HIV. Infectious Disease
Alert, 28(1), 3-5. Loutfy, M. R., Raboud, J. M., Wong, J., Yudin, M. H., Diong, C., Blitz, S.
L., ... & Walmsley, S. L. (2012). High prevalence of unintended pregnancies in HIV‐positive women of reproductive age in Ontario, Canada: a retrospective study. HIV medicine.
References Loutfy, M. R., Sonnenberg-Schwan, U., Margolese, S., Sherr, L., & on behalf
of Women for Positive Action. (2012). A review of reproductive health research, guidelines and related gaps for women living with HIV. AIDS care, (ahead-of-print), 1-10.
Strong, C. (2003). Reproductive assistance for HIV-discordant couples. American Journal of Bioethics, 3(1), 57-60.
Squires, K. E., Hodder, S. L., Feinberg, J., Bridge, D. A., Abrams, S., Storfer, S. P., Aberg, J. A. (2011). Health needs of HIV-infected
women in the United States: insights from the women living positive survey. AIDS Patient Care STDS. 2011 May;25(5):279-85.