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 Obste Gynecol, 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 Hormonal Contracep tion: 32% Consistent Condoms: 54% 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 Obste Gynecol, 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 Obste Gynecol, 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 woman Infected woman Uninfected man Infected man Infected man Infected woman Uninfected woman Uninfected man 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 Sheree Schwartz Helen Rees Courtenay Sprague PEPFAR Patients we work with 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.