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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

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Contraception for HIV-infected Women and Couples

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  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

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