Fertility and HIV

1. Fertility and HIV Vivian Black WITS Reproductive Health and HIV Institute, South Africa 26 July 2012

2. Fertility Desires • HIV infected women and men desire children • ART initiation increases fertility intention • Desire for children changers with time and life events • Focus on women, yet males want children and influence their partners Badell ML et al. Infect Dis ObsteGynecol , 2012 Dyer SJ. J Psychosom Obstet Gynaecol , 2007 Schwarts SR et al AIDS Behav, 2011 Schwarts SR et al PLoS One, 2012

3. Fertility Intentions and Incidence • 850 HIV infected women on ART, aged 18-35 years, were from 4 PEPFAR supported ART sites in inner city Johannesburg, September 2009 – March 2011 Schwartz SR, et al AIDS Behav 2011 Schwarts SR et al PLoS One, 2012

4. Contraceptive use amongst 748 women on ART not trying to conceive Consistent Condoms: 54% HormonalContraception: 32% Dual Use: 15% Unmet Need: 29% Schwartz SR, et al AIDS Behav 2011

5. Fertility desire and contraception uptake - USA Atlanta ID Clinic surveyed 127 HIV positive women 18-50 years. • High rates of sterilization, 44% (18% of whom desired children), 56% were sterilized because they were HIV infected. • Condom use 41% • Low rates of hormonal contraception Badell ML et al. Infect Dis ObsteGynecol , 2012

6. Patient-provider communication • Patient-provider communication about fertility is an important part of HIV prevention

7. Patient-provider communication USA • Only half of women had spoken to their HCW about contraception in previous year • 1/3 had never/not in 5 years spoke to their HCW about contraception • Less than half of women believed IUCD, hormonal contraception was safe SA • Nearly all women (93%) reported that a HCW had discussed condom • Only 48% of women reported that an HIV provider had discussed non-barrier methods • HC use was higher in women whose HCW had discussed HC methods (37% vs. 21%, p<0.01) Badell ML et al. Infect Dis ObsteGynecol , 2012 Schwartz SR, et al AIDS Behav , 2011

8. Consequences of poor communication USA • Half of all pregnancies in the US are un-intended. SA • 170 pregnancies documented in 161 women, • 105 (62%) were unplanned • 56 (53% ) were EFV conceptions • Of these 36 (36%) elected TOP Schwartz SR, et al PLoS ONE 2012

9. Special Groups Perinatally Infected Women/Youth • UK Ireland cohort of 252 women >12 year • 42 pregnancies among 30 women • Median age 18 (14-22 years) • 81% unplanned • >50% of partners unaware of HIV status • 36% elected termination of pregnancy • 33% had detectable VL • 1/21 infants infected with HIV Kenny J et al. HIV Med 2012

10. Special Groups Couples struggling to conceive may increase risky sexual behavior such as multiple partners Same sex relationships Dhont N, et al . Sex Transm Infect 2011

11. Towards a Solution • Health care workers working with HIV infected people need to talk to their patients about fertility intentions regularly. • Integration of family planning services into HIV services.

12. How do we support conception?

13. Different approaches to supporting fertility in HIV infected couples • Resources Available • Resources Not available Infected woman Uninfected man Uninfected man Infected woman Uninfected woman Infected man Uninfected woman Infected man Infected woman Infected woman Infected man Infected man

14. Pre-conception counselling • Reasons for reproductive desire • Disclosure of status • Reproductive options, including risks, risk reduction, costs and chances of success • Balance the risk of natural conception with established risk-reduction methods • Consequences of failure to prevent transmission to partner and child and importance of regular testing • Health of infected partner and woman

15. Minimum pre-conception medical assessment • Exclude STIs through syphilis serology and clinical assessment • Exclude AIDS: Medical examination and CD4 cell count • Those on ART should have an undetectable VL • Screen for infertility through history • Pregnancy: RH, haemoglobin

16. Medical management • Optimise medical condition • Treat any current infection • Treat co-morbid illnesses • Determine ovulatory cycle

17. Fertility and HIV Scenario 1: Negative woman and positive man • The man should be on ART and have suppressed viral load • Assisted techniques – sperm washing , insemination OR in “Resource limited” settings • The couple practice safe sex for most of the woman’s cycle using condoms. • Use ovulatory method and have sex without condom on alternate days during ovulation

18. Criteria for Natural Conception • The responsibility of adherence rests with HIV positive partner • The decision of consenting to unprotected intercourse lay with the HIV negative partner • Limited to 6 months during ovulation period only • Condoms should be used at all other times • HIV positive partner on ART for ≤ 6 months • VL undetectable • Perfect adherence to treatment and medical follow-up • Mutually faithful relationship • No concomitant STI Barreiro, Human Reproduction 2007

19. Fertility and HIV Scenario 2: Positive woman and negative man Ideally woman on ARTs with suppressed viral load • No need to expose man to risk of becoming HIV infected • Conception: sperm collection with insemination at the time of ovulation • Man ejaculates in clean receptacle • Semen drawn up into a large syringe (10 - 20ml) • Syringe placed about 4 – 6 cm in woman’s vagina in prone position and semen pushed out of the syringe • Can be done at home or in clinic.

20. Fertility and HIV Scenario 3:Concordant positive couple • Optimise health • Ensure not on any teratogenic drugs • Risk of horizontal transmission not a concern • Vertical transmission needs to be considered • Natural conception

21. Unsuccessful • After attempting 6 ovulation cycles unsuccessfully, consider reduced fertility. Risk of continuing naturally exposes the partner to risk of HIV infection and may not result in conception • Counsel and if appropriate refer for further work-up • Repeat HIV testing of exposed partner

22. Successful

23. Repeated HIV antibody testing for exposed partners • If woman seroconverts during pregnancy, provide ART as soon as possible as seroconversion is associated with high rates of mother-to-child transmission

24. Important to protect partner after conception Increased risk of HIV-1 transmission in pregnancy: Prospective study among African serodiscordant couples • HIV viral load in genital secretions during pregnancy is increased • Increased risk of HIV transmission from a pregnant woman to her sexual partner Mulago NR et al, AIDS 2011

25. PMTCT • If woman HIV infected, ideally she was on ART prior to conception. She should continue ART throughout pregnancy. • If the woman was not on ART, provide ART if feasible (guideline limitations in some settings), or else provide PMTCT as per local guidelines.

26. Thank-you Acknowledgements Further Reading Bekker L-G, Black V et al. Guideline on Safer Conception in Fertile HIV-infected individuals and couples. The Southern African Journal of HIV Medicine, June 2011. New York State Department of Health. Preconception Care for HIV-infected Women. Guideline summary NGC 8022: New York State Department of Health. Fakoya A, Lamba H et al British HIV Association, BASHH and FSRH Guidelines for the Management of the Sexual and Reproductive Health of People living with HIVinfection2008. HIV Med 2008; 9: 681. • Sheree Schwartz • Helen Rees • Courtenay Sprague • PEPFAR • Patients we work with