Family Planning Choices for Women With HIV

CONTENTS

Home (Key Points)

Supporting the Reproductive Decisions of Women With HIV

Box: Family Planning Is a Key Strategy to Reduce Mother-to-Child Transmission of HIV

Box: When a Woman With HIV Decides About Pregnancy

Box: Helping Women Talk With Their Partners About Contraception and Safer Sex

Box: Information Communication Technology: Mobile Phones Keep Women With HIV in Contact With Care

Women With HIV Can Safely Use Most Contraceptive Methods

Box: Dual Protection Strategies Help Prevent Pregnancy and STIs

Women With HIV Need the Facts About Pregnancy

Box: What People With HIV Need to Know About Pregnancy and
Preventing Pregnancy

Bibliography

Credits

• INFO Report: “Women and HIV: Questions Answered”
• Web Tool: Assess Your Attitudes and Beliefs About People With HIV
• Box: What People With HIV Need to Know About Preventing Pregnancy

• Table 1: Comparing Contraceptive Methods for People with HIV
• Table 2: Drug Interactions: Combined Oral Contraceptives and Antiretroviral (ARV) Medications
• Web Box: Condoms at a Glance

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Women With HIV Need the Facts About Pregnancy

Women with HIV who desire children face risks that need special consideration. Some of the risks can be reduced, and many women can conceive, carry a pregnancy to term, and avoid passing HIV to their infants. To make informed decisions about pregnancy, women and their partners need to know that:

• HIV infection somewhat reduces the chances of conceiving and carrying a baby to term.
• Pregnancy usually will not have a major effect on the progression of HIV disease.
• The chances of poor pregnancy outcomes are greater for women with HIV.
• Without treatment, 1 to 3 of every 10 infants of mothers with HIV will be born with HIV infection, and an additional 1 or 2 in every 10 breastfed infants will be infected. With special care, these odds can be lowered.
• An uninfected sex partner may have to risk infection while trying for conception. (Also see Box: What People With HIV Need to Know About Pregnancy and Preventing Pregnancy)

In addition, women or couples need to consider their own specific situations when deciding about pregnancy—for example, where will the baby receive health care, and will their families help with child-raising?

At an antenatal clinic in Papua New Guinea, a nurse talks to pregnant women about HIV/AIDS. If a pregnant woman does not know her HIV status, getting an HIV test can help her determine whether she needs ARVs to prevent mother-to-child transmission of HIV and how she should feed her infant after delivery. (Photo: UNICEF Papua New Guinea, 2004, Pirozzi)

HIV Infection Reduces Fertility

HIV infection may reduce both female and male fertility, but does not cause complete infertility. Studies find that women with HIV have lower pregnancy rates and birthrates than women without HIV, even after adjusting for factors such as age, breastfeeding, reported frequency of sexual intercourse, and use of contraceptives (50, 68, 76, 82, 92, 185, 188, 192, 217, 259).

How HIV infection reduces fertility is not clear, but it is known that the impact of HIV on pregnancy rates is greatest among women who are symptomatic (50, 82), are at later stages of disease progression (186, 192), or have high viral loads (156). Coinfection with other STIs such as syphilis (which women with HIV are more susceptible to) may further reduce fertility (15, 159). For instance, a large Ugandan study found that HIV infection reduced the likelihood of pregnancy by 65%, whereas infection with both HIV and syphilis reduced the likelihood of pregnancy by 72% compared with the chances of pregnancy among women without either HIV or syphilis (82).

Men with HIV have fewer live, swimming sperm, less ejaculate, and lower total sperm counts than men who do not have HIV (53, 158). Sperm counts are lowest when CD4+ cell counts are low (158). (A CD4+ cell count, also called a T4 cell count, is a laboratory measure of the immune system’s response to HIV. The lower the CD4+ cell count, the weaker the immune system (see From Exposure to AIDS: The HIV Disease Continuum).

Pregnancy Poses Little Risk of Faster HIV Disease Progression

Studies from developed countries suggest that pregnancy has no measurable effect on the progression of HIV disease when compared with HIV progression in women who are not pregnant (69, 136, 182, 189, 225). In the one developing-country study of 140 Haitian women with HIV, however, pregnant women with HIV were 3.7 times more likely to show HIV-related symptoms before women who were not pregnant, but the pregnant women did not progress to clinically defined AIDS any faster than women who were not pregnant (48) (see From Exposure to AIDS: The HIV Disease Continuum, for a definition of clinically defined AIDS).

HIV Infection Increases Risk of Poor Pregnancy Outcomes

For reasons that are not clear, HIV infection increases the risk of poor pregnancy outcomes such as low birth weight, preterm delivery, and miscarriage (18, 44, 133, 184, 186). For example, a meta-analysis found that risk of miscarriage among women with HIV is 2.8 to 6 times greater than the risk among uninfected women (18). In Dar es Salaam, Tanzania, women with HIV who had severe symptoms were more than twice as likely to have infants of low birth weight and about twice as likely to give birth prematurely as women without HIV (34). In a European study women with HIV were 4.5 times more likely than women without HIV to develop postpartum fever (puerperal fever), but they were no more likely to have other signs of infection (65).

Certain opportunistic infections associated with HIV infection can complicate pregnancy (133). Pregnant women with both HIV and malaria face a 2- to 3-fold greater risk for preterm delivery, restricted intrauterine growth, and neonatal death than pregnant women with HIV who do not have malaria (229). Pregnant women with HIV and tuberculosis also are more likely to experience these same complications as well as maternal anemia and low birth weight (171).

Women’s Health Affects the Chances of MTCT

If no particular precautions are taken, women infected with HIV have a 15% to 30% chance of passing the virus to their infants during pregnancy, labor, or delivery (43). If these women breastfeed in typical fashion (give both breastmilk and other liquids or food before six months), breastfeeding will transmit HIV to another 10% to 20% of infants (36, 54, 154). In other words, for every 20 births of women with HIV, 3 to 6 would be born infected, and another 2 to 4 would be infected if breastfed. Thus, without special care, as few as 3 or as many as 10 in every 20 babies would be infected. If treatment and proper feeding are possible, however, the risks can be reduced.

Women with HIV are at greater risk of passing HIV to their infants if they have:

• High viral load,
• Certain other STIs, or
• Malaria or other parasitic infection.

High viral load. Early in the course of infection and late in the course of HIV disease may be when mother-to-child transmission (MTCT) is most likely. Most people are not aware of infection just after it occurs, but a woman who knows that she has HIV and who wants a child can be advised that the chances of MTCT may rise if her health starts to deteriorate.

The risk of MTCT appears to be tied to the level of viral load (an indication of the amount of HIV in the body). When viral loads are high, risk of MTCT is high. Conversely, when viral loads are low, risk of MTCT is low. When viral loads are high, CD4+ cell counts are low. Thus, the level of risk of MTCT roughly corresponds to the inverse of CD4+ cell counts. A CD4+ cell count below 200 x 10⁶ cells per liter of blood indicates high risk of MTCT. Counts between 200 and 500 indicate moderate risk, and counts above 500 indicate low risk (72, 97, 139).

High viral loads occur during primary HIV infection—the first phase of infection, when a person is newly infected with HIV and the virus replicates quickly before the immune system develops antibodies (104) (see From Exposure to AIDS: The HIV Disease Continuum). Thus, if a woman becomes infected during certain stages of pregnancy or while breastfeeding, the chances of MTCT are high. Levels of virus also are high late in the course of infection, when the immune system fails. HIV progresses less rapidly among women who are well-nourished, and maintaining adequate nutrition can help keep viral loads low (see Good Nutrition Helps Women With HIV Stay Healthy in Pregnancy).

Herpes simplex virus (HSV), gonorrhea, and syphilis. Women with HIV who also have HSV infection (HSV is the virus that causes herpes), gonorrhea, or syphilis are more likely to transmit HIV to their infants. Studies in Kenya, Malawi, and the U.S. found that women infected with HIV and either HSV or syphilis were two to five times more likely to pass HIV to their infants during pregnancy or delivery than women who did not have HSV or syphilis (28, 52, 100, 149). In Tanzania women with HIV who had gonorrhea were 5.5 times more likely to pass HIV to their infants during pregnancy than women with HIV who did not have gonorrhea (64).

Screening and early treatment of maternal syphilis and gonorrhea before and during pregnancy may help reduce infant HIV infections. PMTCT programs may want to consider routine screening for syphilis, which is a low-cost test (216). Also, suppressing HSV with the ARV valacyclovir reduces genital shedding of HIV by about 60%, which is assumed to help reduce the chances of MTCT (151). Providers need to advise women with HIV to take additional precautions to prevent STIs if they are considering pregnancy. For women considering pregnancy who are already coinfected with both HIV and another STI, providers need to explain the increased risk of MTCT, provide treatment, and discuss delivery by cesarean section (see 'ARVs can significantly reduce the risk of MTCT'), if available.

Malaria or other parasitic infections. Women with HIV are more susceptible to malaria infection than women without HIV (112, 147), and the presence of HIV doubles the risk for placental malaria infection (presence of the malaria parasite in the placenta) compared with the risk for women who have malaria but who do not have HIV (71, 169). Placental malaria infection in turn increases the chances of MTCT. In Kenya and Uganda pregnant women with HIV and placental malaria were two to three times more likely to transmit HIV to their infants during labor and delivery than mothers with HIV but no malaria (5, 16).

Also, a study in Kenya found that pregnant women coinfected with HIV and one or more parasitic worms (lymphatic filariasis, schistosomiasis, and/or hookworm) were more than seven times more likely to pass HIV to their infants than women with HIV who were not infected with parasitic worms (71).

Special Care Can Help Reduce the Risk of MTCT

Combined, interventions such as ARV medications, cesarean-section delivery, and avoidance of breastfeeding have been able to reduce the risk of mother-to-child transmission of HIV in developed countries to below 2% (58, 97), compared with 25% to 50% (for women who breastfeed as it is typically practiced) without these measures. So far, however, few women in developing countries have access to the necessary services and to safe infant formula. Efforts to provide and encourage replacement feeding where appropriate or, if that is not possible, to encourage and support exclusive breastfeeding are expanding (see 'Safer infant feeding practices'). Access to ARVs for MTCT reduction and to cesarean-section delivery has been slow to expand in the countries hardest hit by HIV. WHO estimated that, at the end of 2005, fewer than 10% of pregnant women with HIV were receiving services—even if only counseling and support—to help prevent HIV transmission to their infants. As a result of insufficient services, an estimated 1,800 infants with HIV were born each day whose infections could have been avoided by these measures (257).

ARVs can significantly reduce the risk of MTCT. ARVs given as prophylaxis (for disease prevention) reduce MTCT of HIV by decreasing replication of HIV—and thus the amount of virus (viral load)—in pregnant women and by protecting newborns during and after exposure to HIV. For pregnant women with HIV not taking ARVs for their own health, WHO recommends providing azidothymidine (AZT) from 28 weeks of pregnancy (or as soon as possible thereafter); AZT and lamivudine (3TC) plus a single dose of nevirapine (NVP) during labor; and AZT and 3TC for seven days postpartum for women and a single dose of NVP and AZT for one week for infants (250). The simplest regimen, and the most practical and cost-effective regimen in resource-low settings, is a single dose of NVP given to the mother at the onset of labor plus a single dose for the infant soon after birth. These regimens can reduce MTCT by one-third to nearly two-thirds (230, 247). Women receiving ARVs as on-going treatment for their own health do not need an additional short course of ARVs during labor, but their infants should be given a single dose of NVP plus AZT for one week after birth or, at minimum, a single dose of NVP soon after birth. ARV regimens may need to be altered before trying for pregnancy, however—in particular, there is concern that efavirenz can cause birth defects if taken during pregnancy (70).

To date, studies have not found that the ARVs given as prophylaxis during pregnancy for MTCT place mothers and infants at greater risk for serious or life-threatening events or increase the likelihood of congenital defects or abnormal growth patterns (218, 250). Still, these treatments are not without drawbacks. Mild anemia can occur in mothers but it is temporary (230). Preterm birth is more common among women using regimens involving two or three ARVs in combination compared with single ARV regimens (110, 119). There is a concern that women who have received nevirapine during a previous pregnancy will develop NVP-resistant mutations of HIV (56, 66), which, if spread, would make it difficult to successfully treat infected mothers and their babies with NVP in the future (247). A few studies have found that NVP resistance in some individual women decreases over time, however (67, 230).

A billboard in Livingstone, Zambia, encourages mothers to seek out services for prevention of mother-to-child transmission of HIV (PMTCT). Although PMTCT services are expanding, progress has been slow in the countries hardest hit by HIV. (Photo: © 2007 Lee Mantini, Courtesy of Photoshare)

Currently, the use of ARVs by the mother and/or baby solely to prevent HIV transmission through breastfeeding is not recommended. (Breastfeeding women with HIV who require ARV therapy for their own health should continue to receive ARVs, however.) A number of clinical trials are underway (247). Preliminary results from a trial in Mozambique suggest that giving a pregnant woman a combination of AZT/3TC/NVP from week 28 of pregnancy and up to one month after delivery significantly reduces HIV levels in breastmilk compared with HIV levels in the breastmilk of women not treated (75).

Benefits and risks of elective cesarean-section. Elective cesarean-section (cesarean-section performed before labor and before rupture of membranes) reduces the risk of MTCT during labor and delivery by 50% to 70%, as it avoids contact between the newborn and the mother’s tissues during delivery (57, 58, 95, 97). In many settings elective cesarean-section is seldom feasible, however (204). Also, women with HIV are more likely than other women to experience complications following cesarean-section, including more fevers, wound infections, and anemia (65, 114, 125, 126). Decisions about elective cesarean-section need to take into account its availability, the status of the woman’s health, whether the technique can be performed safely, and what follow-up care is available (246).

Safer infant feeding practices. Exclusive breastfeeding for six months (giving only breastmilk to infants) poses about half the risk of MTCT posed by six months of mixed feeding (giving both breastmilk and replacement food), according to a large observational study in South Africa (36). At 26 weeks postpartum 15% of infants exclusively breastfed for 24 weeks before switching to replacement feeding had acquired HIV, compared with 27% of infants who were mixed-fed from before 14 weeks and 26% of infants who were initially exclusively breastfed and then mixed-fed from 14 weeks. This study confirms earlier findings from South Africa and Zimbabwe which found that exclusive breastfeeding reduces HIV transmission by one-fourth to one-third compared with mixed-feeding (38, 94).

Replacement feeding eliminates the risk of HIV transmission through breastfeeding. In low-resource settings, however, replacement feeding often poses risks of malnutrition and illness from contaminated water. WHO and other United Nations agencies recommend that mothers with HIV exclusively breastfeed their infants for the first six months of life and then wean the baby over a period ranging from two days to three weeks unless replacement feeding is acceptable, feasible, affordable, sustainable, and safe. If at six months replacement feeding does not meet these five criteria, mothers should continue breastfeeding with additional complementary foods and stop breastfeeding once a nutritionally adequate and safe diet without breastmilk can be provided (253).

Serodiscordant Couples Can Take Steps for Safer Conception

For people with HIV who desire children, an important issue is how to achieve conception as safely as possible when one partner has HIV and the other does not. The options depend on whether the male or female partner has HIV. If the partner of a person with HIV has not been tested, providers can strongly encourage testing so that the couple can take appropriate steps to care for the partner’s health and can make informed decisions. In situations where the partner has never had—and will not get—an HIV test, it is safest to assume that he or she does not have HIV and to take precautions to minimize the risk of HIV transmission.

When a woman has HIV and her partner does not. One option for such couples is to have unprotected sex only when a woman is fertile. This minimizes but of course does not eliminate risk to the uninfected male partner. The most cautious approach may be to have sex just once in a cycle. A woman with a 28- day cycle is usually fertile between days 8 and 15, counting from the first day of menstrual bleeding. Providers can instruct the couple on how to calculate the days when the woman is most fertile (calendar days method or symptoms-based method; for more information see “Family Planning: A Global Handbook for Providers,” at http://www. fphandbook.org). In a study in Spain 62 HIV-discordant couples using such a strategy achieved 76 conceptions between 1998 and 2005. None of the uninfected partners became infected (10).

Theoretically, another option would be in-home insemination with her partner’s sperm. This would pose no risk of HIV infection to the man. Using a simple tool such as a syringe, pipette, or other clean receptacle, the woman or man could insert semen into the vagina at the time that she is most likely to be fertile. The success of in-home insemination has not been studied (11).

When a man has HIV and his partner does not. Achieving pregnancy safely is more difficult in this situation. The only way to avoid the risk of transmitting HIV is artificial insemination using semen from a donor who has been tested and does not have HIV. Nevertheless, there are a number of approaches that may reduce the risk of transmission to the uninfected woman. One approach is to limit unprotected sex to the days that a woman is fertile; and the most cautious approach may be to have sex just once in a cycle. A study in the Democratic Republic of Congo between 1987 and 1990 found that, among 92 couples in which only the male had HIV and 85% of unprotected sex acts occurred during the woman’s fertile period, 14 women became pregnant and 1 woman was infected (188).

Typically, the chances of pregnancy per act of sex during the fertile period are higher than the chances of transmitting HIV per act of sex. The overall chance of pregnancy with one act of unprotected intercourse is 3.1% but varies from 2.9% on day 8 of the cycle to a peak of at 8.6% on day 13 and declining to 7.2% on day 15 (238). The probability of transmitting HIV during one act of unprotected sex generally is 0.8% or less, but it can be higher, depending on factors such as viral load (74, 81, 233).

ARVs suppress viral loads in blood to undetectable levels in almost 70% of patients by 6 months of therapy and in 57% of patients by 12 months, according to a meta-analysis of 10 developing-country studies (98). ARVs also reduce the viral load in seminal plasma (the fluid that nourishes and protects sperm cells). Thus, ARV treatment should reduce the risk that a man will infect his partner (172, 175). Still, some studies have found HIV in the genital tract when none was detectable in seminal plasma (19, 227), and people with undetectable seminal plasma viral loads theoretically can still pass HIV to their partners. Couples should not assume that they are no longer at risk for transmitting HIV during intercourse while using ARVs.

Where available, another option is “sperm washing,” a process that separates sperm from seminal fluid, which carries most of the HIV. This process reduces the concentration of HIV to below detectable limits in most samples. Still, experts recommend testing all processed sperm before insemination (29). The purified sperm are then inseminated directly into the woman’s uterus when she is ovulating and most likely to become pregnant. In U.S. and Italian studies none of a total of 931 uninfected women who received washed sperm developed HIV infection (191, 194). In Italy nearly 80% of the couples achieved pregnancy (191). (The women in this study were given fertility drugs to assure ovulation.) Sperm washing is not widely available in developing countries and too costly for most people.

Finally, giving ARVs to an uninfected woman around the time that she is exposed to HIV during sex, known as post-exposure prophylaxis (PEP), theoretically could help limit HIV transmission (120). Most of the findings on the benefits of PEP come from studies among health care workers exposed to HIV through needle sticks or other accidents in the workplace. Limited evidence from animal studies and observational studies of people suggests that PEP also can reduce the risk of HIV infection through intravenous drug use or sex (201).