B asic standards of reproductive health in relation to HIV and women

1. Basic standards of reproductive health in relation to HIV and women Tomasz Niemiec, MD,PhD Institute of Mother and Child Warsaw, Poland Paris, October 7, 2005

2. The WHO Definition of Reproductive Health Reproductive health is defined by WHO as a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life … T.Niemiec,Paris,2005

3. One of the greatest achievements of the 20th Century was the creation of an international human rights system in which the rights of all are equal. T.Niemiec,Paris,2005

4. Poverty levels are terrific, affecting nearly half the world’s population. United Nations Summit , September 2005 T.Niemiec,Paris,2005

5. Investing in women, young people and reproductive health is necessary to accelerate poverty reduction and development - for this and future generations. United Nations Summit , September 2005 T.Niemiec,Paris,2005

6. Reproductive health problems reflect the impact of poverty and gender discrimination on women’s lives: • Half a million women die from pregnancy-related complications each year; • The feminization of HIV/AIDS – with the numbers of women infected, especially young women, rising rapidly; T.Niemiec,Paris,2005

7. These problems are all largely preventable. The solution lies in empowering women and improving access to reproductive health care T.Niemiec,Paris,2005

8. Unwanted pregnancy, unsafe abortion Complications of pregnancy and delivery Other STD’s Rape, forced marriage, Sexual violence Family Planning Neoplasmas PMTCT Harm Reduction Reproductive Health of People Living with HIV problems? T.Niemiec,Paris,2005

9. Information on Sexuality and Reproductive health Access to Family planning services Access To Appropriate service Access to Comprehensive Antenatal, Safe delivery And post –birth services Freedom And Protection From Sexual abuse Confidentiality, Privacy, And respect When seeking services Access to Quality STI service Prevention of Unsafe abortion And post abortion care Reproductive Health of People Living with HIV Basic reproductive health needs and rights T.Niemiec,Paris,2005

10. Dimensions of the Problem T.Niemiec,Paris,2005

11. Almost half of the 40 million people living with HIV today are women. • Three quarters of all new cases of HIV are sexually transmitted between men and women. T.Niemiec,Paris,2005

12. Contrary to the common belief that married women are ‘safe’, many have been infected by their only partner: In sub-Saharan Africa, 60-80 per cent of HIV-positive women have been infected by their husbands. T.Niemiec,Paris,2005

13. HIV in women in Europe • In 2002, there were an estimated 30,000 newly diagnosed HIV infections in Western and Central Europe, about half in women • Heterosexual transmission has now become the dominant mode of acquisition of infection • Total number of women with AIDS in WHO Europe region is nearly 50,000, nearly all reported from West Europe T.Niemiec,Paris,2005

14. Some aspects of reproductive health and HIV: • Family planning • Pregnancy and prevention of mother-to-child transmission • Drug use • Infertility (discordant couples) • Gynecological conditions (neoplasms,STIs) T.Niemiec,Paris,2005

15. Pregnancy and HIV T.Niemiec,Paris,2005

16. Pregnancy and HIV “When I was found [to be HIV] positive, no one talked to me about my well-being.The doctor told me to do MTP [medical termination of pregnancy] as I had no rightto pass on the infection to my baby.” Woman in Mumbai, India, from PANOS & UNICEF, Stigma, HIV/AIDS andPrevention of Mother-to-Child Transmission (unnumbered page) (2001) T.Niemiec,Paris,2005

17. Pregnancy and HIV • Epidemiology • Transmission • Modes,timing and rates • Risk factors • Maternal, obstetrical, infant • Interventions to reduce risk T.Niemiec,Paris,2005

18. HIV and Pregnancy: Prevention of Mother-to-Child Transmission • Worldwide, each year, two million HIV + women become pregnant • Between 1/4 and 1/3 transmit the disease to their newborns (2,000 new AIDS-infected infants each day) T.Niemiec,Paris,2005

19. HIV and Pregnancy: Prevention of Mother-to-Child Transmission • HIV presentation is the same in both sexes, but the disease has greater implications on a woman’s reproductive health in terms of her ability to cope with pregnancy and transmission of the virus to her unborn and newborn child • During the asymptomatic phase of HIV, most women are unaware of their infection until the disease is diagnosed in their infants. This may cause conflict within the family and the woman might be blamed for bringing the infection into the family T.Niemiec,Paris,2005

20. Children and HIV • 90% infections due to vertical transmission • MTCT can occur in utero, intrapartum or through breastfeeding • Most transmissions occur late in the third trimester T.Niemiec,Paris,2005

21. Vertical Transmission • Timing of Transmission • Intrauterine (+PCR @ 48hrs) 20-60% • Intrapartum (+PCR @ 7d-3mos) 40-80% • Post-Partum/Breastfeeding 14-29% • Rates of Transmission • 15-33% in industrialized countries prior to HAART, now can be <1.8% • 25-45% in developing countries T.Niemiec,Paris,2005

22. Maternal Risk Factors • Higher viral load • VL>1000 • VL <1000: 1% transmission • Low CD4 count • Symptomatic disease or AIDS defining illnesses • STDs • Drug use T.Niemiec,Paris,2005

23. Maternal Risk Factors • Other Possible Risk Factors • Vitamin A deficiency • Primary HIV infection • Smoking • Anemia T.Niemiec,Paris,2005

24. Maternal Viral Load and Risk of Transmission: Women & Infants Transmission Study (WITS) HIV-1 RNA Transmission % N 0/57 32/193 39/183 17/54 26/64 <1000 1000 -10,000 10,001- 50,000 50,001-100,000 >100,000 0 16.6 21.3 30.9 40.6 T.Niemiec,Paris,2005

25. What we can do to reduce the risk of mother-to-child HIV transmission?

26. T.Niemiec,Paris,2005

27. Reducing Transmission • Maternal Interventions • Antiretroviral therapy • Opportunistic Infection prophylaxis • Genital HSV Prophylaxis • Screen and Treat STIs (and BV/yeast?) T.Niemiec,Paris,2005

28. Facts: • The benefit of antiretroviral drugs in reducing mother-to-child HIV transmission greatly outweighs any potential adverse effects of drug exposure or concerns related to development of drug resistance WHO Technical Concultation, 2000 T.Niemiec,Paris,2005

29. Elective Cesarean Section • Recommended if VL >1,000 • AZT, 2 mg/kg loading dose then 1 mg/kg/hr should be started 3 hours prior to surgery • Increased morbidity of cesarean vs. vaginal • Especially if low CD4 counts T.Niemiec,Paris,2005

30. Obstetrical Risk Factors • Prolonged rupture of membranes (>=4hrs) • Chorioamnionitis • Active genital HSV/STI in labor • Episiotomy • Invasive fetal procedures T.Niemiec,Paris,2005

31. Intrapartum Management • Anti-retrovirals • Intrapartum AZT • AZT 2 mg/kg over 1 hour then 1 mg/kg/hr for duration of labor T.Niemiec,Paris,2005

32. Infant Risk Factors • Prematurity • < 37 wks • Birth weight <2500g • Breastfeeding • Mixed breast/bottle feeding • Skin/mucous membrane lesions • Thrush T.Niemiec,Paris,2005

33. Evaluation and Follow upof Infants • Long-term follow-up of HIV and ARV-exposed infants • Support services for the family T.Niemiec,Paris,2005

34. Drug use, reproductive health and HIV T.Niemiec,Paris,2005

35. During the last decades women constitute an increasing number of the drug using population and a larger percentage of them are of the child-bearing age and agrowing number of women become infected with HIV by injecting illicit drugs. T.Niemiec,Paris,2005

36. Policy statement • Local authorities should have a written policy related to the problems of drug using parents. T.Niemiec,Paris,2005

37. These policies should include: T.Niemiec,Paris,2005

38. Availability of services: • All health care services should be available for drug using pregnant women. The availability of these services should not be influenced by the level of acceptance of the recommended medical and social advice by the drug using pregnant women themselves T.Niemiec,Paris,2005

39. Harm reduction: • Easy access to health services should be provided in regard to harm reduction within this population. This should involve outreach programs encouraging drug using women of childbearing age to seek counseling about reproductive health and early entry into perinatal care when pregnant. T.Niemiec,Paris,2005

40. Free of charge treatment or possibility of refunding: • All treatment, counseling, and psychosocial support should be free of charge or covered by insurance according to the general system of health provision in a given country. T.Niemiec,Paris,2005

41. Confidentiality and respect: • Drug dependence and the related risk of HIV transmission are reasons for stigmatization of these patients, especially women. This often makes them reluctant to health care services. Provision of services, counseling and treatment should be realized in respect of the women’s personal needs, choices and rights to professional confidentiality. T.Niemiec,Paris,2005

42. Contraception counseling: • Drug using women who present prior to pregnancy should receive adequate, comprehensive information and counseling concerning family planning and contraceptive measures, including all the aspects of HIV infection and prevention of transmission from mother to child. Contraception counseling should also be given postpartum. For most drug using women postpartum hospitalization is the only chance to give such counseling. T.Niemiec,Paris,2005

43. Methadone treatment: • Pregnant women’s access to drug addiction treatment should be an absolute priority. Availability of these services is the key to successful pregnancy management. This includes appropriate gradual detoxification under medical supervision and substitution treatment for opiate dependence. T.Niemiec,Paris,2005

44. Parent and children’s rights: • The rights of the parents’ and their child should always be respected. By preference, obviously the mother and child should get all possible support to remain together. Foster-care and adoption are alternatives to be considered if mother is unable to provide the stable environment needed for the development of the child. The assessment of mother’s ability to care for the child should be partly a responsibility of the multidisciplinary team. All measures should be undertaken to prepare and counsel the woman about safe motherhood. T.Niemiec,Paris,2005

45. Abortion: • Should be available as an option, based on the general laws in different countries T.Niemiec,Paris,2005

46. Protection against domestic violence: • Drug using women are a group of high risk of domestic violence, pregnancy often adds to it. To provide safe environment for the pregnant woman free of drugs and violence is also one of the key aspects of proper pregnancy management. T.Niemiec,Paris,2005

47. Counseling for HIV Discordant Couples

48. Reproductive counselling to PLWH: To reduce the risk of male to female transmission of HIV To reduce the chances of vertical transmission of HIV

49. COUPLES LIVING WITH HIV Both are with HIV (same viral strain) Both are with HIV (different viral strain) Woman with HIV & uninfected man Man with HIV & uninfected woman

50. Man with HIV & uninfected woman