Assessing and Supporting Reproductive Health Care Needs and Desires of People Living with HIV

Transcription

1 Assessing and Supporting Reproductive Health Care Needs and Desires of People Living with HIV Webinar May 17, 2016

2 Webinar Instructions All attendees are in listen-only mode Everyone can submit questions at any time using the chat feature This webinar has too many attendees for questions to be submitted over the phone. During Q & A segment the moderators will read selected questions that have been submitted.

3 Raise your Hand, Use the Question Feature to Ask Questions, or questions You may also your questions to

4 HHS Office on Women s Health Vision All women and girls achieve the best possible health. Mission The Office on Women's Health provides national leadership and coordination to improve the health of women and girls through policy, education, and model programs. 4

5 Goal: To empower women to make their health a priority Schedule a well-woman visit Get active Eat healthy Pay attention to mental health Avoid unhealthy behaviors 5

6 6 Website

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8 8 Steps for better health by age

9 Disclosures Jessica Terlikowski and Brenda Wolfe have nothing to disclose.

10 Midwest HIV Prevention & Pregnancy Planning Initiative (MHPPPI) Goal: Improve the sexual and reproductive health care of people living with/impacted by HIV Provider and consumer education Lead organization: AIDS Foundation of Chicago Partners: EverThrive Illinois, Midwest AIDS Training and Education Center, Pediatric AIDS Chicago Prevention Initiative, Planned Parenthood of Illinois Priority states: IL, IN, IA, MI, MN, MO, OH, WI Funded by the U.S. Department of Health and Human Services 10

11 By the end of today s training you will: Today s Objectives 1. Have new strategies to meet PLHIV s reproductive health care needs and desires 2. Be able to initiate affirming conversations with WLHIV about fertility desires 3. Be able to support safer conception for sero-different couples 4. Facilitate WLHIV s access to contraception and conception care, resources, supports, and assistance

12 Women and HIV 23% of people living with HIV are women 20% of new HIV infections were in women Black women & Latinas disproportionately impacted Majority of WLHIV are of reproductive age Half of all U.S. pregnancies are unplanned Half of WLHIV learn serostatus during pregnancy

13 Reproductive Health Care Needs and Desires of People Living with HIV

14 Reproductive Rights The basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. --World Health Organization

15 Reproductive Health Care is Important for PLHIV Affirms human rights and reproductive justice Optimizes health outcomes Supports desires and decisions to plan and prevent pregnancies Enables safer conception practices for serodifferent couples, reducing HIV risk between partners and to baby Increases treatment and prevention of STIs for PLHIV and partners

16 PLHIV s Reproductive Health Needs and Desires Health care through lifespan childbearing years and beyond Recognition and respect as sexual beings Access to high quality services and care Ability to build healthy families and space children Provider-initiated conversations with clinicians Sexual experiences (consensual vs. non-consensual) Sexual practices Conception desires and possibilities Contraception

17 PLHIV s Reproductive Desires 75% of PLHIV (women & men) are of reproductive age Estimated up to 252,000 U.S. male-female serodifferent couples (Neshiem et al. 2015) Half of U.S. male-female serodifferent couples desire children Want to understand possibilities, options, and strategies for safer conception (Kessler et al. 2010) Perinatal HIV Hotline calls reflective of this landscape Willing to accept some level of risk (Brown et al. 2015)

18 No ethical reasons to withhold infertility treatment from HIV-affected couple -ASRM Committee Opinion, 2015 TDF/FTC commonly used; practice vigilance for new HIV infections in lactating women -ACOG, Committee Opinion 2014 HIV/Sexually transmitted diseases as a core component of family planning services -CDC MMWR, 2014 Clinical Guidelines on PLHIV and Fertility Pregnancy and breastfeeding are not contraindicates to PrEP -CDC Perinatal Guidelines, 2015 Discuss risks/benefits/alternatives of PrEP with pregnant & breastfeeding women -WHO, 2015

19 Stigma/Biases Structural Barriers Inadequate Provider-Patient Communication Reproductive Health Care Barriers for PLHIV

20 Stigma against WLHIV

21 Stigma appears to be one important factor contributing to the missed opportunities to strategically and safely plan pregnancies with patients and thus preventing full application of the science and knowledge available to prevent new infections while maximizing autonomy and respect for human rights. (Steiner et al. 2013)

22 Structural Barriers to Sexual/Reproductive Health Care for PLHIV Sociocultural Norms Economics Policies Assumptions about who wants/should have children Men s reproductive desires not considered or assessed Men not engaged in preconception conversations or care Majority of PLHIV are at or below the poverty line ADAP formularies exclude contraception No Medicaid expansion in 20 states, including WI KS, & MO SRH attacked at state & federal levels HIV criminalization laws in 33 states, including IA, IL, IN, KS, MI, MO, OH, & WI 18% of WLHIV reported being asked to sign a document about HIV criminalization laws related to nondisclosure, transmission, and/or pregnancy

23 Lack of Provider-Patient Communication

24 Critical Conversations are Lacking Sexual health conversations not occurring with many WLHIV (Positive Women s Network-USA 2013) Few providers initiate pregnancy desires conversation w/ WLHIV Less than 50% WLHIV desiring a baby AND a conversation had that discussion Younger women asked more often than older women (Kessler et al. 2010) Role of suppressed viral load in prevention not widely conveyed (Positive Women s Network-USA 2013)

25 Provider-Patient Communication Barriers Patients Distrust of healthcare system Negative experiences with medical community History of trauma Estimates among WLHIV: IPV 55%; PTSD 30% Feelings of judgement, stigma Providers Limited time Limited SRH knowledge Discomfort managing contraception Lack of violence/trauma inquiry Believe condoms are sufficient Feeling topics are outside scope Assumption other provider is discussing/addressing SRH issues Assumptions about sexual behavior

26 Missed Opportunities Communications gaps result in missed opportunities to discuss: Sexual health Contraception Perception and understanding of ability to have a family Testing and connecting partners to care Preconception care Antiretroviral therapy ARVs impact on health of woman and fetus

27 Why Provider-Initiated Conversations Matter Lack of conversation can be perceived as bias/disapproval Conception attempts may be initiated on own Many PLHIV are unaware it is possible to: Deliver HIV-negative baby Reduce HIV transmission between partners Facilitates conversation between patient and partner Allows for inclusion of partner in the family planning process Enables exploration of pregnancy ambivalence

28 Assessing and Supporting Reproductive Desires

29 Preconception Health Care Not just for women planning pregnancy! Relevant to anyone of reproductive age, including PLHIV Supports health in event of pregnancy Planned or unplanned Reduces unintended pregnancies Promotes awareness, responsibility and active partner participation Results in better health outcomes for parents and baby

30 Topics of Preconception Counseling for PLHIV HIV disclosure Partner status, testing, readiness Contraception options Current treatment regimen Risks and benefits of HIV drugs Viral load levels; medication adherence HIV impact on pregnancy; pregnancy impact on HIV Perinatal and partner transmission prevention strategies Pregnancy spacing Resources available at

31 One Key Question Promotes discussion of: Reproductive plan or pregnancy desires Current sexual practices Safer conception strategies Pre-conception care Contraception needs/options Adoption, surrogacy, etc. HIV-status of partner 31

32 Talking with Patients Who Don t Desire Pregnancy Explain that pregnancy risk is 85% over year when no contraception is used Inform them of the variety of methods available Offer guidance that reflects data available on ARV and contraception drug interactions Remember that fertility desires change with relationships and situations No now doesn t mean not ever

33 Hormonal Contraception and WLHIV Most hormonal contraception is safe, recommended Some ARVs may interact with contraception Interaction concerns SHOULD NOT preclude prescribing patient preferred hormonal contraception

34 Long-Acting Reversible Contraceptives (LARCs) Unknown and underutilized by many women Recommended as first line options 99% effective High satisfaction Highly recommended WLHIV No evidence of interaction with ARVs No evidence of genital tract shedding HIV

35 Safe and can be removed at any time IUDs containing hormone Mirena (5yrs) Skyla (3 yrs) Liletta (3yrs) Copper IUD containing no hormone Paragard (12 yrs) No reaction with ARVs Not Your Mama s IUD Can be used as EC if inserted within 5 days of intercourse

36 Implants Nexplanon Highly effective Contains a progestin Good for three years

37 Depo Provera The Shot Shorter Acting Birth Control Method Progestin Quarterly injection May take a little longer to get pregnant once discontinued Conflicting observational data on link between DMPA and HIV risk No restrictions recommended CDC recommends telling HIV-vulnerable women: That the shot may or may not increase risk Use male or female condoms

38 Emergency Contraception Back-up plan if contraception Fails Is used incorrectly Is not used Doesn t work if already pregnant Not harmful if already pregnant Some women use EC as their contraception (this is not recommended)

39 The Bottom Line on Contraception Inform and offer range of options Educate about the importance of contraception for pregnancy prevention and spacing Talk through what is known and unknown Discuss immediate insertion of LARC post abortion, miscarriage, and delivery Underscore importance of dual protection-- male and female condoms in addition to DMPA Let them decide what is right for them

40 Talking with Patients Who are Unsure For PLHIV: identify knowledge base or concerns Ask follow-up questions of patients who express uncertainty regarding pregnancy desires: Do you know that PLHIV can have HIV-negative healthy babies? Do you intend to have children in the future? Do you feel now is not the right time to become pregnant? Do you have the resources you need? What resources do you need? Do you need help accessing them?

41 Talking with Patients Considering Pregnancy PLHIV can have healthy HIV-negative babies, when In care Following proper medical plan Pregnancy planning is the first step in decreasing perinatal transmission Provide education Reduce anxiety

42 Preconception Health Care Services Discussion of reproductive life plan Medical history Sexual health assessment Screening and referral/treatment for: IPV and sexual violence Alcohol/drug/tobacco use Immunizations Depression Height, weight, BMI, blood pressure STDs (CT, GC, syphilis, HIV) Diabetes Hepatitis Women and Men

43 Check viral load Preparing for Healthy Pregnancy Delay attempting pregnancy until undetectable Treatment suppresses HIV viral load in blood and genital fluids Measure CD4 count CD4 counts <50 can decrease ability to become pregnant Assess ARV regimen for safety in pregnancy Treat co-occurring hepatitis B infection Manage treatment side effects: hyperglycemia, anemia, and hepatoxicity

44 Preparing for Healthy Pregnancy: Partner Readiness Discuss preconception plan with partner and clinicians Screen partner for HIV If partner is HIV-positive, draw viral load Provide necessary care/support/referrals to achieve and maintain undetectable Test and treat for STIs Consider semen analysis for HIV-positive men

45 Viral suppression PrEP/PrEP-ception Artificial/self insemination Timed intercourse Assisted reproductive technologies Safer Conception Strategies

46 Viral Suppression Requires PLHIV consistently adhere to treatment regimen Necessary for optimal health of PLHIV Foundational step for safer conception

47 Artificial/Self Insemination WLHIV and HIV-negative partner Simple Inexpensive Accessible Increase conception chances when done during ovulation Use specimen cup or condom to collect sperm Use needleless syringe to insert semen into vagina

48 Timed Intercourse Condomless sex during peak fertility times Involves patient understanding and tracking ovulation Points to highlight with patients Partner must have suppressed viral load When ovulation occurs How to track ovulation Where to access ovulation kits Use of prevention method when not ovulating

49 PrEP-Ception New option for family building for sero-different couples HIV-negative partner takes PrEP through duration of conception attempts Start daily oral doses 1 month before conception attempt Continue daily oral dose until 1 month after last conception attempt CDC clinical factsheet

50 PrEP-Ception CDC guidance recommends discussion with couples about: Potential risks Adherence to daily doses Continuing condom use after conception to reduce STI and HIV risk Signs of acute HIV infection Urgent need for HIV testing if HIV infection is suspected Discuss pros and cons of staying on PrEP after conception

51 PEP and Pregnancy Option if potential HIV exposure occurs during pregnancy Considerations for PEP initiation same whether pregnant or not HIV-negative Started within 72 hours Complete 28 day regimen Data indicates ARVs during pregnancy don t increase birth defects Enroll your patients in ARV Pregnancy Registry Discuss possibility of transitioning to PrEP

52 Clinical Guidance and Consultation PrEPLine PEPLine

53 Resources You don't have to know the answers You can call and get expert support 24/7 Clinician Consultation Center Illinois Perinatal HIV Hotline hotline

54 Resources Provider checklist and questionnaire FXB Center pre-conception guides for WLHIV and providers HIVE: A hub of positive and reproductive sexual health One Key Question Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults & Adolescents CDC's Medical Eligibility Criteria for Contraception Use

55 Acknowledgements Cori Blum, Howard Brown Health Courtney Chambers, Midwest AIDS Training and Education Center Mary Jo Hoyt, François-Xavier Bagnoud Center Amy Johnson, AIDS Foundation of Chicago Vanessa Johnson, Positive Women s Network Naina Khana, Positive Women s Network Kelly Nowicki, AIDS Foundation of Chicago Ricardo Rivero, Midwest AIDS Training and Education Center Sheila Sanders, EverThrive Illinois Barbara Schechtman, Midwest AIDS Training and Education Center Anne Statton, Pediatric AIDS Chicago Prevention Initiative Sara Semelka, AIDS Foundation of Chicago Danielle Pauk, Planned Parenthood of Illinois Jim Pickett, AIDS Foundation of Chicago Pamela Tassin, AIDS Foundation of Chicago Jessica Terlikowski, AIDS Foundation of Chicago Evany Turk, Positive Women s Network Shannon Weber, HIVE Brenda Wolfe, Planned Parenthood Illinois

56 Raise your Hand, Use the Question Feature to Ask Questions, or questions You may also your questions to

57 Thank you! Contact MHPPPI staff at or (312)