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 61% of HIV cases. Burden on Women •Proportion of women with HIV is increasing in other regions. Source: UNAIDS and WHO, 2007.

5. 75% young women 25% young men Young Women Are Disproportionately Affected HIV among 15- to 24-year-olds in sub-Saharan Africa Source: UNAIDS, 2006.

6. HIV Prevalence among Youth Percentage of 15-24 year-old women and men Source: DHS for Dominican Republic 2002, Cameroon 2004, Kenya 2003, Zambia 2001-2002.

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

8. Pregnant Women Share Burden In many countries of southern Africa, one in three pregnant women are living with HIV. Source: UNAIDS, 2006; UNAIDS, 2006.

9. HIV in Children New HIV infections worldwide, 2007 420,000 among children 2.1 million among adults Source: UNAIDS and WHO, 2007.

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

11. 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 Source: UNAIDS, 2006; Moss, 1991.

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

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

14. 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.

15. 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 HIV-positive • number of future orphans

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

17. 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 Source: Ross, 2002.

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

19. 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 Source: Saada, 2000; Tai, 2007; Brocklehurst, 1998.

20. Clients with HIV:Reasons to Consider Pregnancy • Intense desire to have children • 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.

21. 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

22. 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

23. 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.

24. ARV Therapy Basics in the Context ofFamily Planning

25. 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

26. 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)

27. 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, 2006.

28. 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 4 weeks • multidrug therapy is more effective • Other uses under study Source: Dabis, 2000; CDC, 2005.

29. Why ARV Clients Benefit from Contraception • Reduce stress related to unintended pregnancy • Avoid complicated pregnancy (ARVs can aggravate anemia 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 fetus) “EFZ should not be given to women of childbearing potential unless effective contraception can be assured.” – WHO, 2003 Source: Shelton, 2004; Powderly, 2002; WHO, 2004.

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

31. 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.

32. 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.

33. 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

34. 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 HIV-positive • need to know their HIV status • need access to contraceptives Clients seeking HIV-related services AND Clients seeking FP services

35. 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

36. Benefits of Involving Men • Encourages partner counselling, testing, and disclosure • Helps women act on prevention messages • Helps couples make informed decisions on reproductive health 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.

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

38. Factors Affecting Sexual and Reproductive Decisions • 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) • Stigma regarding condom use • Gender issues/partner opposition

39. Factors Affecting Method Choice Women with HIV may consider: • safety and effectiveness of the method • duration of protection desired • possible side effects • ease of use • cost and access to resupply • effect on breastfeeding (if postpartum)

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

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

42. 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; updated 2008.

43. Category When clinical judgment is limited 1 Use the method 2 3 Do not use the method 4 WHO Eligibility Criteria Source: WHO, 2004; updated 2008.

44. WHO Eligibility Criteria: Examples Medical Condition/ Characteristic Contraceptive Method Category uterine fibroids COCs 1 anemia IUD 2 breastfeeding a baby less than 6 weeks postpartum DMPA 3 current breast cancer hormonal implants 4 Source: WHO, 2004; updated 2008.

45. 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.

46. Pregnancy Rates by Method Spermicides Female condom Standard Days Method Male condom Oral contraceptives DMPA IUD (TCu-380A) Rate during perfect use Female sterilization Rate during typical use Implants 0 10 20 25 30 5 15 Percentage of women pregnant in first year of use Source: CCP and WHO, 2007.

47. 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, 2007.

48. 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 HIV-positive 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, 2007.

49. 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; updated 2008.

50. Why Encourage Dual Method Use Use condoms to protect against STIs/HIV plus another method for increased protection against pregnancy. Reduces: • risk of unintended pregnancy • transmission of HIV between partners • risk of acquiring or transmitting other STIs Dual method use requires ongoing support and encouragement by providers.