Basic 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

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.

4

• Poverty levels are terrific, affecting nearly
  half the worlds population.
• United Nations
  Summit , September 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

6
Reproductive health problems reflect the impact
of poverty and gender discrimination on womens
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

7
These problems are all largely preventable. The
solution lies in empowering women and improving
access to reproductive health care
8
Reproductive Health of People Living with HIV
problems?
9
Reproductive Health of People Living with HIV
Basic reproductive health needs and rights
10
Dimensions of the Problem
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.

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.

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

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)

15
Pregnancy and HIV
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 right to pass on the infection to my
  baby.
• Woman in Mumbai, India, from PANOS UNICEF,
  Stigma, HIV/AIDS and Prevention of
  Mother-to-Child Transmission (unnumbered page)
  (2001)

17
Pregnancy and HIV

• Epidemiology
• Transmission
• Modes,timing and rates
• Risk factors
• Maternal, obstetrical, infant
• Interventions to reduce risk

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)

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 womans
  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

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

21
Vertical Transmission

• Timing of Transmission
• Intrauterine (PCR _at_ 48hrs) 20-60
• Intrapartum (PCR _at_ 7d-3mos) 40-80
• Post-Partum/Breastfeeding 14-29
• Rates of Transmission
• 15-33 in industrialized countries prior to
  HAART, now can be lt1.8
• 25-45 in developing countries

22
Maternal Risk Factors

• Higher viral load
• VLgt1000
• VL lt1000 1 transmission
• Low CD4 count
• Symptomatic disease or AIDS defining illnesses
• STDs
• Drug use

23
Maternal Risk Factors

• Other Possible Risk Factors
• Vitamin A deficiency
• Primary HIV infection
• Smoking
• Anemia

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
0 16.6 21.3 30.9 40.6
lt1000 1000 -10,000 10,001- 50,000 50,001-100,000 gt
100,000
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What we can do to reduce the risk of
mother-to-child HIV transmission?
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(No Transcript)
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Reducing Transmission

• Maternal Interventions
• Antiretroviral therapy
• Opportunistic Infection prophylaxis
• Genital HSV Prophylaxis
• Screen and Treat STIs (and BV/yeast?)

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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

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Elective Cesarean Section

• Recommended if VL gt1,000
• 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

30
Obstetrical Risk Factors

• Prolonged rupture of membranes (gt4hrs)
• Chorioamnionitis
• Active genital HSV/STI in labor
• Episiotomy
• Invasive fetal procedures

31
Intrapartum Management

• Anti-retrovirals
• Intrapartum AZT
• AZT 2 mg/kg over 1 hour then 1 mg/kg/hr for
  duration of labor

32
Infant Risk Factors

• Prematurity
• lt 37 wks
• Birth weight lt2500g
• Breastfeeding
• Mixed breast/bottle feeding
• Skin/mucous membrane lesions
• Thrush

33
Evaluation and Follow upof Infants

• Long-term follow-up of HIV and ARV-exposed
  infants
• Support services for the family

34
Drug use, reproductive health and HIV
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 a growing number of women
  become infected with HIV by injecting illicit
  drugs.

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Policy statement

• Local authorities should have a written policy
  related to the problems of drug using parents.

37
These policies should include
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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

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.

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.

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 womens
  personal needs, choices and rights to
  professional confidentiality.

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.

43
Methadone treatment

• Pregnant womens 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.

44
Parent and childrens 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 mothers 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.

45
Abortion

• Should be available as an option, based on the
  general laws in different countries

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.

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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

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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

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Man with HIV uninfected woman
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HIV IN SEMEN WHERE IS IT?
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ELIMINATING HIV FROM SEMEN
Gradient
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DIFFICULTIES FOR HIV-DISCORDANT COUPLES ACCESSING
ART

• Anxiety over the possibility of infection
• Difficulties in completing the pre-insemination
  screening (cost, confidentiality, logistics)
• Difficulties in reaching the centre
• Long waiting lists leading to drop out
• Possibility of cycle cancellation due to poor
  ovarian response or PCR problems
• Cycle failure or pregnancy loss

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Recommendations

• Access to ART for all couples with HIV
• Semen washing is the mainstone
• ART centres available and accessible
• Programs tailored to needs

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TAKE HOME MESSAGES
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TAKE HOME MESSAGES

• Gender equality and reproductive health are not
  only prerequisites for poverty reduction, but
  also key to accelerating development.

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TAKE HOME MESSAGES

• Investing in women and youth is critical to the
  goals of poverty reduction, lasting peace, and
  national and human security.

58
TAKE HOME MESSAGES

• It is critical to mobilize additional resources
  for HIV prevention the first line of defense to
  halt the epidemic as well as for treatment and
  care for those already infected.

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TAKE HOME MESSAGES

• People need an essential package of services that
  both meets their needs for HIV prevention and
  treatment, as well as addresses other critical
  areas of their reproductive lives - such as
  preventing maternal deaths and unintended
  pregnancies.

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