Preconception Care for HIV-Infected Women

Table of Contents

• I. Introduction
• II. Principles of Preconception Care for HIV-Infected Women of Childbearing Potential
  • A. Prevention of HIV Transmission, Superinfection, and Other STIs
  • B. Optimizing Health/Reducing Risk
  • C. Contraception
  • D. Termination of Pregnancy
• III. Elements of Preconception Care for HIV-Infected Women Considering Pregnancy
  • A. Planning and Timing of Pregnancy
  • B. Effect of HIV on Pregnancy
  • C. Medications Commonly Prescribed in HIV-Infected Pregnant Women
  • D. Reproductive Options
  • E. Effect of Pregnancy on HIV
  • F. Routine Prenatal Care
  • G. Perinatal HIV Transmission
  • H. Guardianship Issues
• References
• Appendix A

I. Introduction

Preconception care is patient education, evaluation, and management aimed to 1) prevent unplanned pregnancies, and 2) decrease the risk of adverse health effects for the woman, fetus, and neonate by optimizing the woman's health and knowledge before planning and conceiving a pregnancy.¹

Because many HIV-infected women report unplanned pregnancies,² all HIV-infected women of childbearing potential (from adolescence through perimenopause) should receive preconception care and counseling, regardless of pregnancy intentions. Preconception counseling provides an opportunity for clinicians to discuss the woman's current health status, ARV regimen, adherence, current and future treatment options, and strategies to either avoid an unintended pregnancy or maximize the chances of a healthy pregnancy outcome.³

II. Principles of Preconception Care for HIV-Infected Women of Childbearing Potential

Recommendations:

Clinicians should provide preconception counseling for all women of childbearing potential during the first few visits after the diagnosis of HIV infection and at least annually thereafter (see Table 1). The patient also should receive preconception counseling after becoming involved with a new sexual partner. The counseling should include the following: (AIII)

• Contraception
• Prevention of HIV/STI transmission
• Importance of maintaining optimal health

Clinicians should: (AIII)

• Be nondirective and respectful of patients' autonomy in decision-making when counseling HIV-infected women about reproductive issues
• Address psychosocial issues that may affect pregnancy, pregnancy outcome, and postpartum care for the infant and make referrals as necessary
• Document the patient's preconception counseling and, with permission from the patient, communicate that information to other providers as necessary

When discussing preconception care, clinicians should stress the importance of optimal maternal health before conception. These discussions should be nonjudgmental, reassuring, and respectful of patients' autonomy in reproductive decision-making. The use of open-ended questions, such as, What are your thoughts about having children now that you are HIV-infected? may facilitate an open discussion and provide an opportunity for preconception counseling.

A. Prevention of HIV Transmission, Superinfection, and Other STIs

Recommendation:

Clinicians should emphasize to all HIV-infected women the importance of barrier protection to prevent transmission of HIV/STIs to partners and acquisition of superinfection from partners, regardless of whether the woman is pregnant or using another form of contraception. (AI)

Preconception care should include a review of safer-sex practices to prevent the sexual transmission of the following:

• HIV to a non-infected partner,
• Re-exposure to HIV (acquisition of new strains) to/from an infected partner, and
• Prevention of other STIs to/from a partner

The risk of transmission of HIV is increased in the setting of STIs. The importance of correct and consistent use of barrier protection during vaginal, rectal, or oral sex for the prevention of both HIV and STI transmission should be stressed. Patients should be informed that because condoms do not cover all exposed areas, they are more effective in preventing infections transmitted by fluids from mucosal surfaces than in preventing infections transmitted by skin-to-skin contact.

B. Optimizing Health/Reducing Risk

Recommendation:

Clinicians should:

• Educate all HIV-infected women of childbearing potential about the importance of maintaining optimal health (AI)
• Consider the possibility of pregnancy in all women of childbearing potential when prescribing medications that are known to be harmful to the fetus (AI)
• Obtain a comprehensive medical history, including previous pregnancies, routine laboratory tests, and perform a physical examination (see Primary Care Approach to the HIV-Infected Patient) (AI)
• Refer to oral health care prior to pregnancy if the patient does not routinely receive oral health care (AII)
• Perform mental health and substance use assessments and refer for treatment when indicated (AI)

Treatment goals for all HIV-infected patients are optimization of health, clinical stability, and improved quality of life. Because of the high rate of unintended pregnancies, the benefits of optimal maternal health and pregnancy outcome should be discussed with all HIV-infected women of childbearing potential. The following should be included in the discussion: sustained clinical and immunologic stability; routine gynecologic care, including Pap test; smoking and alcohol cessation; drug and alcohol rehabilitation, when necessary; and folic acid supplementation, both before and during pregnancy.

The importance of good oral health practices should also be discussed. Poor maternal oral health, such as periodontal disease, prior to pregnancy has been shown to result in pre-term birth⁴; however, periodontal therapy during pregnancy has not been shown to reduce the rate of prematurity.⁵ Clinicians should refer HIV-infected women of childbearing potential for oral health care prior to pregnancy if the patient does not already receive routine oral health care.

C. Contraception

Recommendation:

Clinicians should educate all HIV-infected women of childbearing potential about the following: (AIII)

• Contraceptive options and misconceptions about their use
• Interactions among ARV medications and oral contraceptive pills
• Potential interactions with other hormonal contraception

Clinicians should refer women who request a form of contraception that is outside the expertise of their provider, such as IUDs, to an experienced clinician who can provide the desired contraception. (AII)

Data from the Women's Interagency HIV Study (WIHS) show that highly effective contraception is underused by HIV-infected women.⁶ Clinicians should discuss contraceptive options for both the prevention of unintended pregnancies and the spacing and timing of intended pregnancies. All HIV-infected women of childbearing potential should be counseled regarding dual-protection contraception (i.e., condom and another form of contraception); emergency contraception; misunderstandings about contraception use and HIV infection (e.g., some patients may believe that hormonal contraceptives cannot be used while taking ARV medications); and the importance of planning a pregnancy. Women who request a form of contraception that is outside the expertise of their provider, such as IUDs, should be referred to an experienced clinician who can provide the desired contraception.

Knowledge of available contraceptive options and the effect of ARV drugs on each option enables patients to make informed decisions that result in preventing pregnancy or optimal timing for pregnancy. Certain ARV medications, such as ritonavir, nelfinavir, and lopinavir/ritonavir, can alter the concentration of oral contraceptive pills, thereby reducing the efficacy of the contraceptive. See Appendix A and Contraception for HIV-Infected Women for more information.

D. Termination of Pregnancy

Recommendation:

Clinicians should be aware of facilities/providers offering safe pregnancy termination services in their area for pregnant HIV-infected women who wish to terminate a pregnancy. (AIII)

Some pregnant women, regardless of HIV status, may not want to carry the pregnancy to term. Clinicians should be aware of facilities/clinicians offering safe termination services in their area and refer women who request such services.