1 / 60

Contraception for HIV-infected Women and Couples

Contraception for HIV-infected Women and Couples. Deborah Cohan, MD, MPH Assistant Clinical Professor Department of Ob/Gyn, UCSF. Overview. HIV and fertility Reproductive decision-making Contraceptive counseling Contraceptive methods Hormonal contraception Condoms

cece
Download Presentation

Contraception for HIV-infected Women and Couples

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Contraception for HIV-infected Women and Couples Deborah Cohan, MD, MPH Assistant Clinical Professor Department of Ob/Gyn, UCSF

  2. Overview • HIV and fertility • Reproductive decision-making • Contraceptive counseling • Contraceptive methods • Hormonal contraception • Condoms • Emergency contraception (EC) • Intrauterine devices • Contraception and HIV

  3. What Won’t Be Covered • Microbicides • Cervical barriers and HIV acquisition • Resource-limited settings

  4. HIV and Female Fertility • Decreased fertility??? • Uganda:  fertility by 25% (Ross, et al, 1999) • Cote d’Ivoire:  fertility by 17% (Desgrees, et al, 1999) •  0.4% fertility rate per % HIV preval in ♀population (Zaba, et al, 1998)

  5. HIV and Female Fertility (2) • Increased miscarriages/stillbirths??? • Cote d’Ivoire: OR 1.28 (1.02-1.60) (Desgrees et al, 1998) • Uganda: OR 1.50 (1.01-2.27) (Gray, et al, 1998) • Italy: OR 1.67 (D’Ubaldo, et al, 1998) • U.S.: no difference (Forsyth, AIDS 2002)

  6. HIV and Female Fertility (3) • Possible of  fertility • PID/tubal factor (etiologies STDs) • Menstrual disorders (Harlow, et al, 2000) • Polymenorrhea (< 18d cycle) OR 1.45 (1.0-2.11)

  7. HIV and Female Fertility (4) • Oligomenorrhea (> 90d cycle) OR 1.32 (0.68-2.58) a) especially high viral loads, low CD4 counts b) OR 7.1 (1.1-1000) (Chirgwin, et al, 1996) • Opiates, testosterone, malnutrition ( BMI) • Direct effects of HIV on uterus, tubes, ovaries? • ART improves fertility?

  8. HIV and Male Fertility • 250 HIV+, 38 HIV-fertile men; cross-sectional • HIV+:  vol.,  concentrat.,  motility,  nl morphol. • No difference in count, wbc • 166 HIV+; cross-sectional • No AZT, cd4 > 200 = nl semen analysis • No AZT, cd4 < 200 = abnl SA • AZT: nl SA and  wbc regardless of CD4 Muller 1998; Politch 1994

  9. HIV and Male Fertility (2) • Regardless of possible risk of sub-fertility or infertility, HIV+ women and partners of HIV+ men get pregnant….

  10. Unintended Pregnancy in U.S. • 50% of all pregnancies are unintended • 1/2 of these are in women USING CONTRACEPTION • Immense personal and societal implications and costs

  11. U.S. Pregnancies: Unintended vs. Intended Intended (51%) Unintended (49%) Unintended Births (22.5%) Elective Abortions (26.5%) Henshaw: Fam Plann Perspect 1998;30:24-29.

  12. Pregnancy Scenarios • Planned pregnancy • WIHS: 2040 HIV+, 561 HIV-neg • 3.5% HIV+ vs. 9% HIV- (p < 0.01) (Wilson, et al, 1999)

  13. Pregnancy Scenarios (2) • Unintended pregnancy • Termination (TAb) of pregnancy • TAb: 28% (Italy), 47% (2x national average, Australia), 58% (Sweden) (Smits, 1999; Greco, 1999; Thackway, 1997, Lindgren, 1998)

  14. Pregnancy Scenarios (3) •  TAb’s if HIV dx after pregnancy dx a) 10.6/100 PY vs. 3.1/100 PY (p=0.001) (Hankins, et al, 1999) •  TAb’s after March 1994 (Europe; van Benthem 2000) a) 4.3/100 PY vs. 1.4/100 PY after 3/94

  15. Reproductive Decision-Making • Perception of HIV risk • Knowledge of risk reduction methods • Clinical course of HIV • Adaptation to HIV status of self/partner • Disclosure of HIV status

  16. Reproductive Decision-Making (2) • Health concerns for self, couple, offspring • Desire to parent • Influence of partner, family, culture, peers, providers • Availability of contraception, abortion services

  17. Reproductive Decision-Making (3) • Not pregnant at/since HIV diagnosis • No desire for future preg: (n=27) • MTCT risk usually overestimated, guilt, risk of meds • Negative opinions of HIV+ women becoming pregnant Kirshenbaum 2004

  18. Reproductive Decision-Making (4) • YET…strong desire for motherhood, pressure from partners • Desire for future preg: (n=5), 4/5 w/o prior pregnancies • undetectable viral load, ART and c-section to prevent transmission Kirshenbaum 2004

  19. Reproductive Decision-Making (5) • Pregnant after HIV diagnosis (n=3) • Less trusting of risk-reduction strategies than 5 desiring preg. • Pregnant at HIV diagnosis (n=12), all had term preg. • 50% not wanting subsequent pregnancies • “lucky” this time, overestimated MTCT risk, many tubal ligation • Subsequent preg: desire to correct past parenting mistakes

  20. How to counsel those not wanting to conceive…

  21. Contraceptive Counseling:General Principles • Establishing need • Contraception history • What worked and didn’t? Side-effects tolerable/intolerable? • Fertility desires • Timing of future pregnancies; permanent vs. reversible • Hormonal vs. non-hormonal

  22. Contraceptive Counseling:General Principles (2) • Non-contraceptive benefits (co-existing med. probs.) • Beliefs about contraceptive options • Sexual history and relationship dynamics • Concordance/discordance of HIV-status

  23. Contraception Failure (1st Year) Hatcher: Contraceptive Technology 16th Edition 1994.

  24. Pros and Cons of Contraception Options

  25. Pros and Cons of Contraception Options (2)

  26. Contraceptive Choices and HIV • Post-partum • 83 HIV+, 218 HIV-neg (1995) • PPTL: OR 2.9 (1.4-5.9) • OCP: OR 0.2 (0.1-0.5); condoms: 0.7 (0.4-1.3) Lindsay Ob Gyn 1995; Wilson JAIDS 2003; Wilson STD 2003

  27. Contraceptive Choices and HIV (2) • 258 HIV+, 228 HIV-neg. (1996-98) • Condoms at 6 mos.: OR 5.61 (3.42-9.22) • Consistent condom use: OR 2.31 (1.35-3.94) • OCP: OR 0.54 (0.30-0.98) • No method: OR 0.30 (0.14-0.65) • 179 HIV+, 182 HIV-neg. • Dual protection at 6 mos.: OR 2.75 (1.16-6.50) Lindsay Ob Gyn 1995; Wilson JAIDS 2003; Wilson STD 2003

  28. Issues for HIV+ women choosing hormonal methods…

  29. OCPs and ART Interactions • Increased levels of estradiol (EE)/norethindrone (NE) • APV ( NE/EE), ATV ( NE 110%, EE 48%), IDV ( NE 26%, EE 24%) • EFV ( EE 37%) Mildvan JAIDS 2002; http://hivinsite.ucsf.edu; USPHSTF, 3/23/04; Frohlich Br J Cl Phar 2004

  30. OCPs and ART Interactions (2) • Decreased levels of EE/NE • NFV ( NE 18%, EE 47%), RTV ( EE 40%), LOP ( EE 42%) • NVP ( EE 20%) • Clinical implications? 50mcg EE pill? Extended/continuous cycle? Mildvan JAIDS 2002; http://hivinsite.ucsf.edu; USPHSTF, 3/23/04; Frohlich Br J Cl Phar 2004

  31. OCPs and ART Interactions (3) • Decreased levels of ART with concurrent EE/NE • Amprenavir (1200mg): APV AUC  22%, Cmin  20% • No change in saquinavir (HGC) pK parameters Mildvan JAIDS 2002; http://hivinsite.ucsf.edu; USPHSTF, 3/23/04; Frohlich Br J Cl Phar 2004

  32. Hormonal Contraception and Other Drug-drug Interactions • Increased hormone metabolism: • Rifampin, rifabutin • Griseofulvin, toglizatone • Phenobarbital, carbamazepine, phenytoin • Primidone, topiramate • St. John’s Wort • Clinical implications • 50 mcg EE pill? Extended/continuous cycle?

  33. DMPA and Viral Set-Point • 161 Kenyan sex workers with acute infection • DMPA assoc.  viral load @ 4 mos. after infxn. • HIV-1 RNA  + 0.33 log/copies • No association seen with OCPs • GUD assoc. HIV-1 RNA  + 0.029 log/copies/month but no  viral set-point Lavreys, JID 2004

  34. Hormonal Contraception and HIV shedding • OCPs •  cervical proviral shedding; cross-sectional, n=318, Kenya • Low-dose OCPs OR 3.8 (1.4-9.9) • High-dose OCPs (50mcg E2) OR 12.3 (1.5-101) Mostad Lancet 1997; Marx 1996; Wang AIDS 2004

  35. Hormonal Contraception and HIV shedding (2) • Progesterone •  cervical proviral shedding (Mostad, et al, 1997) • DMPA OR 2.9 (CI 1.5-5.7) • Macaque data: subQ progesterone implants (Marx, et al, 1996) • Thinned the vaginal epithelium and  SIV vaginal transmission • 7.7-fold  # SIV DNA-positive cells in the vaginal lamina propria Mostad Lancet 1997; Marx 1996; Wang AIDS 2004

  36. Hormonal Contraception and HIV shedding (3) • DMPA, OCP, POP initiation; longitudinal cohort •  cervical DNA shedding OR 1.62 (1.0-2.63), no change RNA Mostad Lancet 1997; Marx 1996; Wang AIDS 2004

  37. Contraception, Condom Use and Partner Status • n=1232 HIV+ women in US, 12 cities/states • 47% women used condoms in past year • No condom use associated with • Tubal ligation OR 1.72 (1.28-2.33) • OCP’s OR 1.44 (1.0-2.08) • HIV+ steady partner OR 1.40 (1.04-1.87) • Steady partner with unknown status OR 1.72 (1.28-2.31) Diaz 1995

  38. Contraception, Condom Use and Partner Status (2) • No condom use INVERSELY associated with • Foam OR 0.01 (0.00-0.09) • Cervical barrier OR 0.36 (0.14-0.90) • Rhythm or w/d OR 0.18 (0.06-0.54) • Consistent condom use • Wilson, WIHS 561 HIV-, 2040 HIV+ • 57% if condoms+ 2nd contracep. vs. 67% if condom use Diaz 1995

  39. Contraception, Condom Use and Partner Status (3) • Contraceptive use and partner status • n=575 HIV+ women (429 HIV-neg. partner) • Partner status: 91% contra use if HIV-neg. vs. 69% if HIV+ • Consistent condom use: OR 6.1 if HIV-neg. partner • OCP and IUD use: OR 2.1 if HIV+ partner

  40. Contraception, Condom Use and Partner Status (4) • EC use assoc with inconsistent condoms: OR 2.0 if partner HIV-neg. or HIV+ • age 40-49 yr old: OR 0.3 if HIV+ partner

  41. Emergency Contraception • Prevents pregnancy after unprotected sex • “Morning-after” pill, post-coital contraception, Yuzpe method, Preven™, Plan B™ • Could prevent 1.7 million unintended pregnancies and reduce abortions by 50% • 1-888-not-2-late

  42. EC Use • Should use within 120 hours of unprotected sex • 2 doses total: 2 at same time vs. 1 dose q12 hrs. • Dose • 1 Plan B™ tabs (0.75 mg LNG) • 2 Preven™ tabs (0.25 mg LNG + 0.05 mg EE) • 4-5 combo OCPs • 20 POPs, such as Ovrette™ (0.075 LNG) • OTC anti-emetic if OCP’s or Preven™ 1 hr. prior

  43. EC: Other Options • RU 486 • Most effective (100%) • Fewest side effects • Expensive, not available • Copper IUD • Should use within 7 days of unprotected sex • Expensive but great long-term contraception

  44. ECP: Mechanism • Will NOT interrupt an established pregnancy • Ineffective but not harmful if already pregnant • Interferes with implantation via effects on endometrium and/or tubal motility • Inhibits ovulation when given in 1st half of cycle

  45. When is EC needed? • Condom breaks or slips off • No birth control is used, including rape • 2 or more consecutive OCPs are missed • Depo-Provera injection 2 or more weeks late

  46. Required Pregnancy test (only if could be pregnant by history) Brief review of contraindications (history of DVT/PE if giving estrogen-containing EC) Counseling Not Required Office visit Routine pregnancy test Prescription in some states!!! ECP: Pre-Rx Screening

  47. EC: Counseling • Efficacy • Prevents 75-88% of pregnancies that would have occurred • Approx. 2% of those who use will become pregnant • Side effects: 50% nausea, 20% vomit (with estrogen- containing pills, much lower with progestin only) • Repeat dose if vomits < 1 hour after taking

  48. EC: Counseling (2) • Safety: very safe. No long-term effects • Pre-existing pregnancy: will not be terminated by this method but will not be harmed either • Effective birth control methods • Review future contraceptive plans • STI exposure? • Next period should be < 3 weeks • If no period, pregnancy test

  49. Advantages of Progesterone-Only EC • Plan B™vs. Ovral® or Preven™: • Less nausea (23% vs. 50%) • Less vomiting (5.6% vs.18.8%) • No anti-emetic necessary • Rare replacement doses because less vomiting • More effective (88% vs. 75%)

  50. Advance Provision of EC THE SOONER THE BETTER • Some effect up to 5 days • Some effect if one dose only • Over-the-counter in Alaska, California, Hawaii, Maine, New Mexico, Washington and Europe

More Related