A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 12: Family Planning and Pregnancy
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intercurrent STDs should be treated, and attempts to
conceive should be well timed around ovulation to avoid
unnecessary exposures during periods of decreased
fertility. The American College of Obstetricians and
Gynecologists has recently endorsed the use of
reproductive technology in HIV-infected patients (ACOG,
2004). Which patients should be offered assisted
reproduction and what the optimal methods are of
decreasing heterosexual and perinatal HIV transmission
must be determined.
When should pregnancy testing be done?
Since most pregnancies are unplanned, the diagnosis of
pregnancy frequently occurs late in the first trimester,
when organogenesis is nearly complete. In order to
make the diagnosis earlier, pregnancy tests should be
done when sexually active women have:
• Late or missed menses (unless she is using Norplant
or Depo-Provera)
• Irregular bleeding (unless she is using Norplant or
Depo-Provera)
• New onset of irregular bleeding after prolonged
amenorrhea with Norplant/Depo-Provera
• New onset of pelvic pain
• Enlarged uterus or adnexal mass on exam
In addition, women with the potential of becoming
pregnant should be tested before starting potentially
teratogenic therapies such as efavirenz (EFV), which
is the only antiretroviral drug that is contraindicated
in pregnancy. Patients should be alerted to potential
teratogenic effects on the fetus, and suitable
contraception should be prescribed.
What contraceptive methods are recommended
for women with HIV who do not want to
become pregnant?
Condoms are the most common contraceptive method
used by women living with HIV. Condoms, consistently
used, have the added advantage of providing protection
against STDs, including potential reinfection with HIV.
This benefit should be emphasized when contraceptive
advice is given to an HIV-positive or at-risk woman even
if she is not seeking or does not need contraception but
is sexually active.
Hormonal methods of contraception are also frequently
used (delivered orally, by injection, or by skin patch).
However, there are many important drug interactions
between hormonal contraceptives and drugs used to
treat HIV infection and HIV-related complications (see
next question).
What are the most common drug interactions
between oral contraceptives and drugs used in
HIV disease?
Oral contraceptives significantly interact with
amprenavir/fosamprenavir (APV/FAPV), efavirenz (EFV),
lopinavir (LPV), nelfinavir (NFV), nevirapine (NVP), and
ritonavir (RTV); an additional method of contraception,
such as condoms, is recommended. Similarly, other
drugs commonly used by HIV-infected patients,
including tetracycline, rifampin, oral anticoagulants,
beta-blockers, and antidepressants interact with
oral contraceptives, and an additional means of
contraception is advisable. Indinavir and atazanavir do
not appear to have an interaction.
What contraceptive methods are not highly
recommended for women with HIV who do not
want to become pregnant?
Spermicides: Generally, a spermicide should be
used along with a barrier method to increase its
effectiveness. However, in some studies nonoxynol-9
(the active ingredient in spermicidal contraceptives)
has been found to cause vaginal irritation and epithelial
inflammation when used as the sole contraceptive
method and on a regular and frequent basis. This may
increase the risk of HIV transmission.
Intrauterine Device: The intrauterine device (IUD) is
not recommended for HIV-infected women. The IUD is
associated with pelvic inflammatory disease and is also
associated with increased menstrual flow. Some studies
even suggest that this device is linked to increased
susceptibility to HIV transmission.
PREVENTING MOTHER-
TO-CHILD TRANSMISSION
(MTCT)
Which are the current recommendations for
HIV testing of pregnant women?
Since prevention of vertical transmission (from mother
to child) of HIV is so effective, identification of HIV
infection in all women who are pregnant is imperative.
Therefore:
• HIV testing should be a routine part of prenatal care
for all women. The “opt out” method, in which HIV
testing is included in the routine bloodwork and
pregnant women have to refuse the test, results in
higher test rates and should be used.
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau