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The Peterborough AIDS Research Network &
The AIDS Committee of Durham Region
Central East Opening Doors
Oshawa, Ontario
Friday October 10th 9:30-11:00am
Myth: “I’ll Never Have Children”
Mona Loutfy, MD, FRCPC, MPHInfectious Diseases Specialist & Clinical Researcher
Women’s College Research Institute, Women’s College Hospital & Maple Leaf Medical Clinic, Toronto, ON
I am HIV positive.
• HIV and pregnancy– Getting pregnant– Reproductive care– Preventing vertical transmission– Managing HIV while pregnant
Can I have a baby?
?
?
??
?
?
?
?
The Women and HIV Research Program
• I AM HIV-POSITVE, CAN I HAVE CHILDREN?
• ANSWER: YES– Increased life expectancy and
decreased illness– Reduced vertical transmission to <
0.5% with ARVs and no breast feeding; Caesarian section in some cases
BIG QUESTION #1
The Women and HIV Research Program
BIG QUESTION #2
• I AM HIV-POSITVE, I WANT TO BECOME PREGNANT, HOW DO I DO IT SAFELY?
• ANSWER: YES; PREFERABLY WITH A DOCTOR’S GUIDANCE– Three issues:
• Reducing horizontal transmission – b/w partners • Reducing vertical transmission – mother -> child*• Keeping mother and baby healthy
*Details in DHHS guidelines – http://aidsinfo.nih.gov/guidelines/
Canadian HIV Fertility Program
VISION:
To champion a collaborative
program
that guides and assists
people living with HIV in
Canada
with their fertility desires
and pregnancy planning
in a holistic, ethical,
supportive and
medically sound manner
The Women and HIV Research Program
Canadian HIV Fertility Program Diagram
• One of Program’s Goal: to have the discussion of pregnancy, reproduction, pre-conception planning as part of routine HIV care– Between all HCP & HIV-positive patients
• Why: many reasons– Allow for discussion of contraception, sexual health,
harm & transmission reduction, criminalization– We want pregnancies of HIV-positive women to be
planned in order to improve maternal & infant health, and reduce vertical and horizontal transmission
The Women and HIV Research Program
Issues Related to Pregnancy Planning and HIV
Fertility and HIV:
Four main issues need to be considered:1) Prevention of Vertical Transmission
• Viral transmission from the mother to the child2) Healthy pre-conception3) Prevention of Horizontal Transmission
• Viral transmission between partners or interacting individuals
4) Fertility issues• If the individual or couple has infertility
Picture from: http://www.tthhivclinic.com/overview_home.htm 1Perinatal HIV Guidelines Working Group 2007 http://aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf.
The Women and HIV Research Program
21%
8%4%
1%0
10
20
30%
Tra
ns
mis
sio
n
None AZT Alone
Less PotentCombo
PotentCombo (PI)
Women & Infants Transmission Study, 1990-1999Cooper E et al. JAIDS 2002;29:484-94
More Potent Antiretroviral Regimens are Associated with Lower Perinatal Transmission
The Women and HIV Research Program
HIV Pregnancy Guidelines
Guidelines Updated – 2014:• Centers for Disease Control and Prevention. U.S.
Public Health Service Task Force recommendations
for use of antiretroviral drugs in pregnant HIV-1-
infected women for maternal health and interventions
to reduce perinatal HIV-1 transmission in the United
States.
– Including use of ARVs & C/S and not breastfeeding
– Up to date guidelines:
http://aidsinfo.nih.gov/guidelines/
The Women and HIV Research Program
General Principles for Pregnancy Planning
• Taking Folic Acid: 1 mg a day for 1-3 months before and during 1st trimester of pregnancy
• Not smoking and drinking • Maintaining a balanced diet• Terminating the use of recreational drugs
11
The Women and HIV Research Program
Antiretroviral drugs and fertility• Preference is to have HIV+ person on appr. Drugs
before pregnancy– Any ARVs except Efavirenz, D4T, ddI, ddC in women – i.e. 3 ARVs – 2 NRTIs (e.g. Combivir, Kivexa, Truvada) +
boosted PI or NNRTI or Integrase Inhibitor– For >3-6 months with viral load <40 copies/mL– Future mother and father should not have received HCV
treatment for 6 months before conception
• Exceptions:– Women - long-term or slow progressor who doesn't need
ARVs for her own health (i.e. CD4 > 500 cells/uL), can wait until 12-14 weeks gestation
The Women and HIV Research Program
Prevention of Horizontal Transmission
• Different clinical scenarios:
1. HIV+ woman with HIV- man (serodiscordant) or who is single or in same sex relationship
2. HIV+ man and HIV- woman (serodiscordant)
3. HIV+ man and woman (seroconcordant)
4. HIV+ man who is single or in same sex relationship or couple seeking egg donation or surrogate mother
• Different clinical scenarios have different risk of and require different strategies to prevent horizontal transmission
13
The Women and HIV Research Program
For all scenarios
• Review all different options for insemination/conception attempt & continuum of risk including:– Unprotected intercourse (on ART, full viral suppression)– Unprotected intercourse with timed ovulation (on
ART, full viral suppression)– Home insemination (i.e. turkey baster method)– Intrauterine insemination (IUI) (in fertility clinic)– Sperm washing followed by IUI– Other: IVF, ICSI, gestational carrier, adoption
14
The Women and HIV Research Program
Fertility Issues• Possibly increased in HIV; Age issue
• Fertility investigations
• Options for fertility treatment:– Ovulation stimulating drugs– Intrauterine Insemination (IUI)– In Vitro Fertilization (IVF)– Intracytoplasmic Sperm Injection (ICSI)
During Pregnancy• Centers for Disease Control and
Prevention. U.S. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. – July 31, 2012 & March 31, 2014
• http://aidsinfo.nih.gov/guidelines/
Summary of what is new in DHHS Guidelines – July 2012
• Included piece on Pre-concepetion • Atazanavir/ritonavir now a preferred
drug in pregnancy along with Kaletra– Use in combination with Combivir
(preferred), Kivexa (if HLA B-5701 negative) or Truvada (alternative)
• Treating with ARVs earlier in pregnancy – i.e. no later than week 12 of gestation– Some start ARVs right away when
pregnant, even 4 or 6 weeks gestation
Summary of what is new in DHHS Guidelines – July 2012
• If an HIV+ woman becomes pregnant on ARVs – do not change ARVs if safe– More harm from changing; poss. nausea
with new regimen; risk of stopping– Even Sustiva (Atripla) can continue; only
said not to use in first 6 weeks gestation• If woman presents late in pregnancy
(i.e. 3rd trimester) or with very high viral load, add Raltegravir to regimen– Commonly use Truvada with Kaletra +
Raltegravir
• Changes to use of intravenous (IV) zidovudine during labor if VL < 400c/mL
Summary of what is new in DHHS Guidelines – March 2014
• Kivexa and Truvada added as preferred
NRTI to Combivir• Atazanavir/ritonavir and Kaletra still
preferred • Efavirenz now preferred NNRTI after 8
weeks gestation• Raltegravir – alternative
The Women and HIV Research Program
Scenario #1
• 27 year old HIV+ woman with HIV- male partner
– She is on Atripla with VL < 50 copies/mL & CD4 count 480 cells/uL & they want to get pregnant
– How do you counsel them?
The Women and HIV Research Program
Scenario #1 – HIV+ woman with HIV- male partner
• Counsel her to switch from Atripla since before pregnancy; start folic acid 1-5 mg per day
• Insemination options– Unprotected sex with timed ovulation– Home insemination with syringe– Assisted insemination – in fertility clinic (intra-uterine
insemination)
• How to do home insemination– Time ovulation (1 day per month; 14 days before
next FDMP) or insert semen on day 11, 13, 15, and 17 of cycle
– Use a turkey baster or syringe
The Women and HIV Research Program
Scenario #2
• Couple: HIV+ man and woman in their late twenties
– Both on ARVs (he is on Atripla and she is on Truvada + Isentress ) with VL < 50 copies/mL & good CD4 count values
– Referred for consideration of and assistance with pregnancy planning and related issues
The Women and HIV Research Program
Scenario #2 – HIV+ man and woman• She can stay on her ARVs & him as well; she
is to start folic acid
• Insemination options– Unprotected sex on ART with timed
ovulation – HPTN052 STUDY– Sperm washing in fertility clinic followed by IUI
• Issues– In this scenario – it is recommended that
both individuals be taking ARVs with VL < 50 copies/mL
– Risk of SUPERINFECTION because of discordance of virus in genital secretions
The Women and HIV Research Program
HPTN 052 StudyRandomized Control Trial
Compare early versus delayed (CD4 < 250) ART for HIV-1 positive patients having 350-550 CD4 per mm3 and in stable sexual relationship with uninfected partner –outcome:• Transmission to uninfected partner (linked)
893 couples in Early Therapy Arm; 882 couples in Delayed Therapy Arm
28 HIV-transmissions were linked: 27 in Delayed Arm; 1 in Early Arm (occurred at 3 months post-ARVs) (0.1 per 100 person-years) [HR 0.04 (CI 0.01-0.27); p<0.001] = 96% reduction of HIV transmission with ART
The Women and HIV Research Program
Sharing information: PamphletsAvailable in French & English at www.catie.ca
Study Overview: What is CHIWOS?
Current Study Provinces
Potential Future Study Provinces
• CHIWOS: the Canadian HIV WOmen’s Sexual and Reproductive Health Cohort Study
• Cohort of about 1400 women living with HIV in BC, ON, QC• 5 year study: April 1st 2011 to March 31st 2016• Anchored in Community-based Research principles• Guided by Critical Feminist, Anti-Oppression and Social Justice
frameworks
CHIWOS: Study Goals
• Among HIV-positive women
–To assess barriers to and facilitators of women-specific HIV/AIDS services use
–To assess the impact of such patterns of use on sexual, reproductive, mental and women’s health outcomes
CHIWOS Study Design
• Recruitment at clinics, ASOs, PRAs, and aims to enrol 350 women from QC & BC and 700 from ON (esp. hard to reach women)
• The survey instrument: online; at baseline & then every 18 months
• Using COMMUNITY-BASED RESEARCH PRINCIPLES
• Surveys done with PRAs – 21 in ON, 8 in BC & 8 in QC• Regional sampling goals in each province • Prioritizing harder-to-reach and marginalized
populations in order to learn more about their experiences, and to better meet their needs
Sampling Targets for Ontario
Population Target Actual Required
Younger women 70 38 32Older women 70 77 NoneTrans women 35 8 27LGBQQ2S Women 70 63 7
Aboriginal women 70 41 29ACB women 70 157 None‘Other' women of colour 70 46 24
Not accessing care 70 27 43History of IDU 70 60 10History of sex work 70 34 36
Region Target Actual Required Percentage Complete
Toronto 288 202 86 70%Ottawa 87 65 22 75%Central West 80 41 39 51%South West 70 17 53 24%Central East and Eastern 70 19 51 27%Northern 70 16 54 23%
Regional Targets
Priority Population Targets
Indicates <60% of target met
The Women and HIV Research Program
This is an Issue of Sexual and Reproductive Rights
“All couples and individuals have the right to decide freely and responsibly the number and spacing of their children and to have
access to the information, education and means to do so.”
World Health Organization, UN Population Fund, Joint United Nations Programme on HIV/AIDS (UNAIDS), and International Planned Parenthood Federation. Sexual and reproductive health and HIV/AIDS: A framework for priority linkages, 2005. Available at http://www.who.int/reproductive-health/stis/docs/framework_priority_linkages.pdf .
“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.
For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”
The Women and HIV Research Program
Acknowledgements
I would like to thank the Peterborough AIDS Research Network & the AIDS Committee of Durham Region for inviting me to speak and to be partners in these important knowledge
exchange activities
35
Thank You!Our Team
Women and HIV Research Program Staff
Canadian HIV Fertility Program Investigators, Staff & StudentsCHPPG Development Team
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