TNF Gestational Age Incidence of RDS by mikeholy

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									Fertility Regulation
in the Setting of HIV:
What are the
Controversies?



Jane Hitti, MD, MPH
University of Washington
Controversy #1
Aren’t condoms sufficient
 contraception for HIV-affected
 heterosexual couples?
Risk of Events Per Single Act
of Unprotected Intercourse
50%     Gonorrhea,
        Syphilis
40%


30%                               Peri ovulatory

20%     Chlamydia

10%                               4-5 days pre ovulation
        HIV (if co factors)       During menses
 0
        Infection                  Pregnancy


                Sources: Anderson (1999); Wilcox (1995)
                                 Slide from Ward Cates
Estimated Date at which Events
would Occur from 2 Acts of
Unprotected Intercourse Per Week

  Chlamydia      Pregnancy HIV (if cofactors)



   Syphilis
   Gonorrhea
  Jan.   April      July   Oct.       Dec.


                              Slide from Ward Cates
Dual protection


    Sexually    Unintended
  transmitted   pregnancy
    infection
      Contraceptive Failure Rates
            15%




            10%
Annual                                                            Perfect
Pregnancy                                                         Typical
Rate
            5%




            0%
                  Condom     Pill      DMPA       IUD     Sterilization




    Hatcher et al, Contraceptive Technology 17th edition, 1998
Dual protection for HIV-positive
women
 HIV-positive women are more likely
  to use condoms consistently and
  less likely to use other methods of
  contraception
 Reliance on condoms as a primary
  contraceptive method increases risk
  of unintended pregnancy
Controversy #2
Are other methods of contraception
 safe for HIV-infected women,
 particularly those on ART?
  Safety of contraception
  (risk of death per 100,000 woman years)

        20

        15

        10
                                                             Age >= 35

         5

         0
              Cars       Term       OC        BTL        First
                      pregnancy                       trimester
                                                      abortion


Hatcher et al, Contraceptive Technology 17th edition, 1998
Controversy #3
Why do ART clinical trials and roll-out
 programs need to be concerned with
 family planning?

(Can’t someone else do this?)
    WHO Four-phase Strategy for
    Perinatal HIV Prevention


Prevention of   Prevention of   Prevention of     Support for
HIV in          unintended      transmission      mother and
women,          pregnancies     from an HIV-      family
especially      in HIV-         infected
young           infected        woman to her
women           women           infant



  Phase 1         Phase 2         Phase 3            Phase 4


                                       Slide from Ward Cates
Single-Dose Nevirapine vs. Effective
Contraceptive Services (1000 HIV-infected Women during 1 Year)

                          500
     Number of Children




                          400

                          300

                          200

                          100

                           0
                                Usual Care   NVP Only     CS Only      CS/NVP

                          Perinatal Transmission   BF Transmission   Future Orphans


                                                                Slide from Ward Cates
Contraception to Prevent HIV Sequelae
     Effective contraception for HIV-infected women
      who do not wish to become pregnant prevents
      more infants from becoming infected than
      single-dose NVP, and also decreases the
      number of future orphans
     This remains the BEST KEPT SECRET in HIV
      prevention
     We urgently need more research on optimal
      contraceptive approaches for HIV-infected
      women


     Cates, Sex Trans Dis 2004;31:3-7

								
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