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Reproductive Health and Preconception Care of HIV-Infected Women

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Title: Reproductive Health and Preconception Care of HIV-Infected Women Author: FXB Last modified by: Becky Carlson Created Date: 4/23/2010 4:41:11 PM – PowerPoint PPT presentation

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Title: Reproductive Health and Preconception Care of HIV-Infected Women


1
Reproductive Health and Preconception Care of
HIV-Infected Women
  • Development Implementation of National
    Recommendations

2
Disclosure
  • With support from the
  • Centers for Disease Control and Prevention
  • The findings and conclusions in this presentation
    are those of the authors and do not necessarily
    represent the views of the Centers for Disease
    Control and Prevention.

3
Objectives
  • To briefly describe the importance of caring for
    the reproductive health of HIV-infected women in
    the US.
  • To describe the process of developing
    national-level recommendations to improve the
    reproductive health of HIV-infected women.
  • List selected recommendations made by the Expert
    Panel on Reproductive Health and Preconception
    Care of HIV-infected Women.
  • To discuss progress toward implementing these
    recommendations to date.

4
Preconception Care of HIV-infected Women (1)
  • Reproductive health needs not being met
  • Separation of GYN and HIV care
  • Preconception counseling and care not being
    addressed pro-actively
  • Reproductive health care often not a priority for
    patients or providers

5
Preconception Care of HIV-infected Women (2)
  • With improved survival and health and decreased
    risk of MTCT, many HIV women are choosing to
    conceive
  • Effective contraceptive is underused unplanned
    pregnancies are common
  • Women face barriers related to stigma, safe
    conception with serodiscordant partners, and
    other issues

6
Preconception Care of HIV-infected Women
7
Chain of Events Leading to an HIV-infected Child
  • The proportion of women . . .
  • ? Who are HIV-infected
  • ? Who become pregnant
  • ? Who do not seek prenatal care
  • ? Who are not offered HIV testing
  • ? Who refuse testing
  • ? Who are not offered ARV prophylaxis
  • ? Who refuse ARV prophylaxis
  • ? Who do not complete ARV prophylaxis
  • ? Whose infant does not receive ARV

    prophylaxis
  • ? Whose child is infected despite
    prophylaxis

Adapted from IOM, 1998
8
Steps to Reducing Perinatal HIV Transmission
  • ? Primary HIV prevention in women
  • ? Comprehensive preconception/interconception
    care
  • ? Prevention of unintended pregnancy in HIV
    women
  • ? Accessible, affordable, welcoming prenatal
    care
  • ? Universal prenatal HIV testing, including
    3rd trimester repeat testing in areas of
    high-incidence
  • ? Re-offering testing to those who
    initially decline
  • ? Offer ARV treatment/prophylaxis to all
    HIV-infected women
  • ? Adherence support for ARVs
  • ? Rapid test for women with
    undocumented HIV status in labor
  • ? ARV prophylaxis for women
    identified in labor
  • ? ARV prophylaxis of all
    HIV-exposed newborns
  • ? Comprehensive services for mother and
    infant

Were working on it!
FXB Center UMDNJ, 2002, 2009
9
Estimated number of births to women living with
HIV infection, 2000-2006
2006 estimate (8,650 8900) is 30 gt 2000
estimate (6075 6422)
Office of Inspector General (Fleming), 2002
Whitmore, et al. CROI, 2009
10
Live Births Among HIV Women Before and After
HAART Availability Sharma, et al. AJOG 2007
  • Comparison of live birth rates 1994-1995
    (pre-HAART era) and 2001-2002 (HAART era) in HIV
    and HIV- women 15-44 yrs
  • In HAART era 150 increase in live birth rate
    among HIV women vs. 5 increase among HIV- women

11
Clinicians Fail to Routinely Provide Reproductive
Counseling to HIV-Infected Women in the US
(Averitt Bridge et al. 2008)
  • Women Living Positive Survey
  • Interviewed 700 HIV women
  • 31 were contemplating pregnancy or had been
    pregnant
  • 48 were not asked by their HIV provider if they
    wanted to have a child
  • Of women who had thought about pregnancy or who
    were pregnant
  • 41 had not discussed HIV treatment change in
    event of pregnancy
  • 29 said their HIV provider did not explain the
    effects of HIV medication on them or their baby

12
Contraceptive Use Among US Women with HIV (Massad
et al. J Womens Health 2007)
13
Cumulative Incidence of First Pregnancy in 174
Perinatally HIV-Infected Sexually Active Girls
Age gt13 Years, PACTG 219C Brogly SB et al. Am J
Public Health 2007
Screen for pregnancy in HIV-infected Adolescents!
By age 19 years, 24.2 of sexually active girls
had been pregnant at least once (6 had 2nd
pregnancy, 1 had 3rd)
14
Background of Recommendations
  • Spring 2008
  • Key informant interviews
  • Literature review
  • Key topics, process, invitees identifed
  • July 2008
  • Expert Panel sponsored by CDC/FXB
  • 32 participants governmental, academic and
    community representatives

15
The Meeting
  • Presentations laid groundwork
  • Facilitated small group work
  • Development of national recommendations with
    action steps
  • Integrate RH and HIV care
  • Primary HIV prevention
  • Large group report back with discussion
  • One Wish
  • Buy-in for ongoing process

16
After the Meeting
  • Recommendations prioritized
  • High/low impact and resources
  • Expert Panel ongoing planning calls
  • Publication and dissemination of recommendations
  • AIDS - Journal of the International AIDS Society
  • APHA 2009
  • AIDS Alliance Voices 2010
  • ANAC 2008 2010

17
Policy Recommendations
  • Integrate adult and perinatal US treatment
    guidelines on preconception care
  • Organize talking-points about data needs and
    present to stakeholders in funding research
  • Advocate to CMS for reimbursement of services
  • Advocate for Ryan White to include additional
    funding for women
  • Include Title X grantees to improve linkages
  • Co-locate clinics
  • Conduct Special Project of National Significance
    (SPNS) projects to demonstrate integration of
    Title X and Ryan White care providers and
    services
  • Collaborate with ACOG on defining preconception
    care in context of HIV infection

18
Program/Services Recommendations
  • Assemble and disseminate best practices that link
    Title X agencies and Ryan White agencies
  • Add a HRSA quality indicator on preconception
    care
  • Develop trainings for HIV providers that increase
    comfort and knowledge about HIV and pregnancy
  • Hold joint trainings for HIV and Title X
    providers
  • Advocate to the AETCs to increase their focus on
    womens health
  • Develop tools for busy HIV providers to
    streamline preconception care and counseling
  • Create mentoring program for new HIV providers

19
Research/Data Recommendations
  • Perform a fishing expedition of existing data
  • Perform research that will address the following
    gaps in data
  • of HIV-infected women who deliver per year?
  • of HIV-infected women who get pregnant each
    year?
  • How many of these pregnancies are repeat
    pregnancies?
  • Conduct studies on
  • the efficacy of hormonal contraception for
    HIV-infected women
  • the effectiveness of reproductive health
    technologies for HIV-infected women on HAART
  • Pre- exposure prophylaxis (PrEP) for discordant
    couples

20
Progress on Recommendations (1)
  • Integration of adult and perinatal guidelines
  • Joined forces with like-minded advocates to write
    AIDS correspondence piece
  • Joint training for family planning and HIV
    providers
  • ACOG survey
  • Perinatal HIV screening practices
  • Routine HIV screening practices
  • Useful preconception care tools

21
Progress on Recommendations (2)
  • Publication and promotion of recommendations
    include Title X and HIV experts
  • Preconception care and counseling tool
  • CDC Institute on perinatal prevention, including
    preconception care, at Ryan White All-Grantees
    meeting in 2010

22
Progress on Recommendations (3)
  • Preconception care incorporated into CDCs
    national framework for perinatal elimination
  • Letter to Office of National AIDS Policy
  • Ongoing work of the perinatal elimination
    stakeholders group

23
Conclusions
  • Assuring the reproductive health for HIV-infected
    women in the US is a means to an end the end
    being comprehensive care for women and progress
    toward the elimination of HIV-infection in
    children.
  • The assembly of experts and ongoing working
    groups are a mechanism to forward changes to both
    clinical care and HIV policy in the US.

24
Thank You
  • To Dr. Jean Anderson for many of her slides for
    this presentation
  • To the members of the CDC/FXB Expert Panel
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