Contraception for Women and Couples with HIV

1. Contraception for Women and Couples with HIV

2. Introduction • HIV/AIDS epidemic disproportionately affects women • Role of family planning in alleviating the burden of HIV • Reproductive choices and decisions for clients with HIV • ARV therapy basics in the context of family planning • Ensuring that services meet the needs of clients with HIV • Contraceptive options for women and couples with HIV • Family planning counselling for clients with HIV

3. HIV/AIDS Epidemic Disproportionately Affects Women

4. In sub-Saharan Africa,women make up 57% of HIV Cases Burden on Women Source: UNAIDS, 2004.

5. Young Women Are Disproportionately Affected HIV among 15- to 24-year-olds in sub-Saharan Africa 75% young women 25% young men Source: UNAIDS, 2004.

6. Example: Prevalence of HIV in Kenya Percentage of population by sex and age Source: Kenya DHS, 2003.

7. Pregnant Women Share Burden In many countries of southern Africa, one in five pregnant women are HIV infected. Source: UNAIDS, 2002; CIDA, 2004.

8. 560,000 casessub-Saharan Africa HIV in Children Among children, 640,000 new HIV infections worldwide in 2004 Source: UNAIDS, 2004.

9. Children Orphaned by AIDS Consequences: • psychosocial impact • health risks • nutritional deficiencies • economic deprivation • increase in HIV infection risk

10. Why Are Women Vulnerable? Cultural and societal factors • gender inequities • limited opportunities • economic dependence on men • imbalance in sexual relationships Possible biological factors • large vaginal surface allows more exposure • cervical ectopy may facilitate acquisition

11. Role of Family Planning in Alleviating the Burden of HIV

12. Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIV-infected women Prevention of trans-mission from an HIV-infected woman to her infant Support for mother and family Family planning and effective use of contraceptives Role of FP in HIV Prevention Source: WHO, 2002.

13. FP Complements Other Programs to Reduce Infant Infections/Deaths Benefits of integrating family planning and nevirapine programs – annual projection of infections and deaths averted Source: USAID, 2003.

14. Benefits of Providing FP Services For women and couples with HIV: • improves health/well-being of families and communities • spacing/limiting births • prevents unintended pregnancies, thus reducing: • number of infants born infected • number of future orphans

15. Unmet Need for Family Planning is High Percentage of married women of reproductive age Source: Population Reference Bureau and DHS, 1999 – 2003.

16. Unmet RH Needs of Young Women Evidence: • high STI/HIV rates • unintended pregnancy • mortality/morbidity from unsafe abortion Causes include lack of: • information/education/communication skills • access to adolescent-friendly RH services

17. Reproductive Choices and Decisions for Clients with HIV childbearing pregnancy contraception

18. Pregnancy in Women with HIV • Does not accelerate disease • One-third pass HIV to newborn during pregnancy, delivery, and breastfeeding • Possible increased risk of stillbirth and low birth weight Positive developments: • ARV therapy improves health/longevity • PMTCT reduces vertical transmission • Wider availability of support and care services

19. Clients with HIV:Reasons to Consider Pregnancy • Emotional need • Pressure to have children • Fear that older children may die • Concern about infertility • Reassured by PMTCT • Optimism about ARV • Avoid generating suspicions • Apprehension about disclosing status Source: Preble, 2003.

20. Clients with HIV:Reasons to Avoid Childbearing • Similar concerns to women without HIV: • economic status • desired family size • ideal spacing • Concerns about health and quality of life • Fear of transmitting HIV • Anxiety about leaving orphans • Concerns about limited access to help

21. Access to Information/Services is Key • Consider reproductive choices • Plan for the future • Avoid unintended pregnancy • Reduce HIV transmission to children • Reduce transmission to partners

22. Many Women with HIV Want to Use FP Pregnancyrate among women with HIV in Rwandan study 22% During this period, contraceptive use increased from 16% to 24%. 9% Source: King, 1995.

23. ARV Therapy Basics in the Context ofFamily Planning

24. improve immune function decrease viral load ARV Therapy Overview • Inhibits replication of the virus • Slows disease progression; improves quality of life • Different drugs attack virus at different stages of replication • Combine three drugs into HAART “cocktail” for best results

25. Classes of ARV Drugs • NRTIs – Nucleoside reverse transcriptase inhibitors • NtRTIs – Nucleotide reverse transcriptase inhibitors • NNRTIs – Non-nucleoside reverse transcriptase inhibitors • PIs – Protease inhibitors • Entry inhibitors (other new classes under development)

26. NNRTI Standard HAART Regimen = NRTI NRTI + OR PI HAART Therapy Regimens ARV therapy is complex and should only be offered by trained providers. Source: WHO, 2002.

27. Use of ARV Drugs for HIV Prophylaxis • Prevent mother-to-child transmission (PMTCT) • drug regimen depends on availability, cost, resistance, possible side effects • reduces vertical transmission by 34% to 50% • Postexposure prophylaxis (PEP) • start as soon as possible; continue 2 to 4 weeks • multidrug therapy is more effective • Other uses under study Source: Dabis, 2000.

28. Why ARV Clients Benefit from Contraception • Reduce stress related to unintended pregnancy • Avoid complicated pregnancy (ARVs can aggravate anaemia and insulin resistance, which are common in pregnancy) • Have access to wider range of ARV drugs if not pregnant or at risk of pregnancy (some ARVs have potential harmful effects on foetus) “EFZ should not be given to women of childbearing potential unless effective contraception can be assured.” – WHO, 2003

29. Ensuring That Services Meet the Needs of Clients with HIV

30. Fertility decision: desire pregnancy? Pregnancy desired No Yes 2. Informeddecision(s):contraceptive method? HIV/STI prevention? Pregnancy Contraceptive Ongoing HIV counselling counselling counselling Intended Safe/effectivecontraception pregnancy 3. Treatment decision(s): ARV therapy for self and partner? PMTCT? ARV PMTCT treatment services No Yes No Yes Choices for Clients with HIV Adapted from: Cates, 2001.

31. Clients’ Family Planning Rights All individuals and couples have the right to: • access information and services • a variety of methods from which to choose • make an informed, voluntary choice of contraceptive method • receive their method of choice Clients should be supported in exercising their reproductive rights, regardless of their HIV status.

32. Ensuring Informed Choice Effective counsellors: • listen carefully • empathize with client • help clients make their own decisions • are not influenced by personal biases • provide accurate information

33. Why Integrate HIV and FP Services Share common needs and concerns: • are often sexually active and fertile • are at risk of HIV infection or might be infected • need to know their HIV status • need access to contraceptives Clients seeking HIV-related services AND Clients seeking FP services

34. Why Integrate HIV and FP Services continued... Creates programmatic synergies including: • more attractive to potential clients • increases access to wider range of services • helps overcome HIV stigma • opportunities for follow-up and support for drug or method adherence

35. Benefits of Involving Men • Encourages partner counselling, testing, and disclosure • Helps women act on prevention messages • Helps couples make informed decisions on reproductive goals and prevention strategies • Improves client satisfaction and adoption, continuation, and successful method use Integrated RH services can provide a valuable opportunity to involve men in a meaningful way.

36. DECISIONS DECISIONS Contraceptive Options for Women and Couples with HIV

37. Factors Affecting Decision to Use Contraception • Health/well-being of self, partner, children • Access to ARV therapy • Fears related to disclosing HIV status (rejection, violence, financial loss) • Knowledge about contraceptives (including cultural myths and misconceptions) • Gender issues/partner opposition • Stigma regarding condom use

38. Factors Affecting Method Choice Women with HIV may consider: • safety and effectiveness of the method • whether it is short-term, long-term, or permanent • possible side effects • ease of use • cost and access to resupply • effect on breastfeeding (if postpartum)

39. Factors Affecting Method Choice continued... • how it interacts with other medications, including ARVs • whether it provides protection from HIV/STI transmission and acquisition • whether partner involvement or negotiation is required

40. Medical Eligibility for Contraceptives • evidence-based recommendations • expert periodic reviews • 19 contraceptive methods • variety of medical conditions including HIV infection, presence of AIDS, and use of ARV therapy

41. WHO Eligibility Criteria Category Description When clinical judgment is available 1 No restriction for use Use the method under any circumstances 2 Benefits generally outweigh risks Generally use the method 3 Risks generally outweigh benefits Use of method not usually recommended, unless other methods are not available/acceptable 4 Unacceptable health risk Method not to be used Source: WHO, 2004.

42. Category When clinical judgment is limited 1 Use the method 2 3 Do not use the method 4 WHO Eligibility Criteria Source: WHO, 2004.

43. WHO Eligibility Criteria: Examples Medical Condition/ Characteristic Contraceptive Method Category uterine fibroids COCs 1 anaemia IUD 2 breastfeeding a baby less than 6 weeks postpartum DMPA 3 current breast cancer hormonal implants 4 Source: WHO, 2004.

44. Contraceptive Method Options • barrier methods • oral contraceptive pills • injectables • implants • intrauterine device (IUD) • female and male sterilization • lactational amenorrhoea method (LAM) • fertility awareness-based methods Couples with HIV have a wide range of methods from which to choose.

45. Pregnancy Rates by Method Spermicides Female condom Diaphragm w/spermicides Male condom Oral contraceptives Depo-Provera IUD (TCu-380A) Rate during perfect use Female sterilization Rate during typical use Norplant 0 10 20 25 30 5 15 Percentage of women pregnant in first year of use Source: Hatcher, 2004.

46. Pregnancy rates: Male Female perfect use 2% 5% typical use 15% 21% Condoms • Prevent both pregnancy and STIs/HIV when used consistently and correctly • In real-life situations, correct and consistent use may be difficult to achieve Source: Hatcher, 2004.

47. Condoms Prevent HIV/STI Transmission • Typical use: 80% reduction in HIV incidence • Consistent use: infection rate less than 1% per year in discordant couples • With infected partner: inconsistent condom use is as risky as using no condom at all • Prevents STIs transmitted through body fluids • less effective for skin-to-skin contact STIs Source: Weller, 2003; Deschamps, 1996; Hatcher, 2004.

48. Condom Use by Clients with HIV • Prevent STI/HIV transmission • Prevent possible superinfection with a different HIV strain • Are less effective in typical use than some other methods for pregnancy prevention • Consistent and correct use should be encouraged Source: WHO, 2004.

49. Why Encourage Dual Method Use Use condoms to protect against HIV/STIs and another method to prevent pregnancy. Reduces: • risk of unintended pregnancy • transmission of HIV between partners • risk of acquiring or transmitting other STIs Dual method use may not be easy to achieve.

50. Counselling about Dual Method Use Users of more effective methods may be less likely to use condoms. Encourage clients to consider: • limitations of a single-method approach • their individual risk of pregnancy • whether partners have HIV or other STIs • the negative consequences that may result