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HIV and younger
women
Women for Positive Action is an educational program funded by AbbVie
Contents
Introduction
Transition of care
Treatment considerations in younger women
Emotional health
Stigma and disclosure
Sexual and reproductive health issues
Examples of initiatives for younger women
Introduction
Women for Positive Action is an educational program funded by AbbVie
Young women and HIV – the statistics
‘Young people’ are defined as those aged 15-24 years1
Globally, there are over five
million young people living
with HIV2
In sub-Saharan Africa, HIV
prevalence among young
women is more than twice as
high as among young men1
Over 60% of all young
people living with HIV are
young women3
Every hour, 50 young
women are newly infected
with HIV4
Young women with HIV can now be expected to have a near
normal life expectancy5
1. UNAIDS, 2013; 2. UNAIDS, 2012a; 3. UNAIDS, 2012b
4. UNAIDS AIDS by the numbers, 2013; 5. Hogg, 2013
Two populations of young women live
with HIV infection globally
Perinatally
acquired HIV
(PAH)
• Acquired in utero, during birth
or via breastfeeding
Non-perinatally
acquired HIV
(N-PAH)
• Acquired during childhood or
adolescence
• Usually through sexual
transmission or IV drug use
Perinatally and non-perinatally
acquired HIV
Non-perinatally
acquired HIV (N-PAH)
• Globally, young people account for 39%
of all new adult HIV infections1
• In Europe (2012), 11% of newly
reported cases of HIV were among
young people2
• Each day, >2,400 young people
contract HIV3
• Women account for 47% of all new
adult infections1
Every hour, 50 young women are
newly infected with HIV4
Perinatally acquired HIV
(PAH)
• The average age of children with PAH in
many European cohorts is now over 13
years5
• In the UK, almost a third of children with
PAH are ≥15 years old5
• In 2012, there were approximately 1.5
million pregnant women living with HIV6
‒ In developed-countries, MTCT of HIV is a rare
event (<1% in Western/Central Europe)7
‒ Rates of >30% still seen in some developing
countries, therefore children still being born
with HIV8
With effective treatment, many girls
with PAH are surviving into young
adulthood and beyond9
1. UNAIDS, 2013; 2. Janiec, 2013; 3. UNAIDS, 2012a; 4. UNAIDS AIDS by the numbers, 2013;
5. CHIPS Study, 2011; 6. UNICEF Stocktaking report, 2013; 7. ECDC, 2012; 8. UNAIDS, 2012b; 9. Mofenson and Cotton, 2013
Young women are more biologically
susceptible to HIV
•
Cervical ectopy or an “immature cervix”1
•
Increased mucosal surface area for mucosal HIV
exposure compared with men2
•
Increased likelihood of trauma to the immature genital
tract during sex1
•
More likely than males to experience asymptomatic STIs,
and the presence of STIs may enhance transmission of
HIV1
1. Canadian AIDS Society, 2012; 2. Yi et al, 2013
RISK FACTORS
Risk factors and risk reduction
strategies in younger women



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





Biological susceptibility
Early sexual debut
Cross-generational sex
Low perception of risk
Substance use
Transactional sex
Low socioeconomic
status
Lack of empowerment
within relationships
Fear of abandonment
Lack of access to health
services
Intimate partner
violence
Anal sex
INTERVENTIONS






Gender-specific riskreduction education
Improved access to sexual
and reproductive health
services
Delayed child marriage
Access to condoms
Economic support
Programmes to address
cultural norm
http://www.unicef.org/esaro/7310_Gender_HIV_prevention_among_youth.html;
http://data.unaids.org/GCWA/GCWA_BG_prevention_en.pdf; Cluver, 2013
Transition of care
Women for Positive Action is an educational program funded by AbbVie
Transition of care is defined as . . .
The ‘purposeful, planned process that addresses the
medical, psychosocial and educational/vocational needs
of adolescents and young adults with chronic physical
and medical conditions as they move from child-centred
to adult-orientated health care systems’
GOAL: To ensure the provision of uninterrupted, coordinated,
developmentally- and age-appropriate, and comprehensive care
before, during, and after the transition
CHIVA Guidance on Transition for Adolescents living with HIV 2011
Increasing numbers of girls are
transitioning towards adult services
In the CHIPS study
(n=1,835 children
living with HIV in the
UK)1
• 37% of young
people in paediatric
care are ≥15 years
of age and
preparing for
transition
• >25% have already
transitioned
A similar pattern is
seen in most well
resourced
countries with
access to
HAART1
CHIPS= Collaborative HIV Paediatric Study
MDT=Multidisciplinary team
Little evidence
available on the
experiences and
outcomes for
those who have
transitioned
It is suggested
that MDT
transition services
can improve
healthcare
experiences
for young
people2,3
1. CHIPS, 2013; 2. Campbell, 2010; 3. Bundock, 2011
Steps towards successful transition of
care
PHASES OF TRANSITION
• Starting the process in discussion with
parents / carers
Last years in
primary
school
• Starting discussions with the
young woman
• Full knowledge of HIV diagnosis
• Increasing autonomy / privacy
• Combined consultation with adult team
• Fully integrated into adult clinic
Late
adolescence
CHIVA Guidance on Transition for Adolescents living with HIV 2011
Successful transition of care requires
partnership from all stakeholders
The child
•
•
•
•
Spend time with paediatric health professionals alone
Input into choice of adult care centre/transition plan
Meet with adult care providers
Agree which shared care health professionals are permitted to receive a copy of the discharge
summary
• Consider engaging with peer support
Families/Carers
• Help to develop confidence and skills to negotiate relationships and to delay early sex and resist
peer pressure
• Help to develop independence
• Support adherence
• Provide guidance and encouragement and maintain openness and honesty
Health professionals
• Build trust, respect and rapport
• Develop comprehensive transition plan
• Offer appropriate information and advice, which is easy to understand, to encourage safe choices
around sexuality and health
• Provide details of support groups/peer support
• Introduce adult services and practitioners gradually
• Address psychosocial needs as well as medical
• Offer support to families/carers
CHIVA, 2011
Young women entering transition
experience myriad challenges
• Stigma & disclosure
Psychological
issues
• Impact of HIV in other family members
• Diagnosis in adolescence
• Migration and cultural aspects
• Emotional wellbeing
• Adherence
• Drug resistance
Medical challenges
• Prolonged exposure to HAART
• Neurocognitive impact of HIV
• Safe sex and pregnancy prevention
Relationships and
sexual health
• Sexual health
• Negotiating relationships and disclosure
CHIVA Guidance on Transition for Adolescents living with HIV 2011
Specific challenges to successful
transition by route of HIV acquisition
Perinatal acquisition1
Non-perinatal
acquisition1
No previous knowledge
of HIV status
Non-disclosure to
primary caregiver
Loss of emotional support
High rates of homelessness
and incarceration
Obstacles in achievement of
career milestones
Stigma of being a substance
user or a teenage mother
More complex clinical issues
than those with N-PAH
N-PAH, perinatally acquired HIV
High rate of disengagement
from services2
1. NY State Department of Health AIDS Institute, 2011; 2. Hughes, 2013
Challenges faced by transition services
Differences in
expectations and
clinic cultures
Adolescent/family
resistance to change
Communication
challenges
Difficulty for
paediatric care team
in separating from
long-term patients
Identifying providers
who are willing/able
to offer transitional
care
Inadequate time to
offer comprehensive
support
Challenges
to transition
Lack of knowledge of
accessing adult
services
1. Hamblin, 2011; 2. NY State Department of Health AIDS Institute, 2011
Transition as a positive experience
Help young women to live a ‘normal’ life and not
be treated differently
Limited stigma
Ensure young women are able to talk about HIV
with family, friends and/or partners
Develop strong relationships with individual
healthcare professionals
Ensure effective learning about HIV and
treatment
Help young women to manage HIV, taking
treatment and accessing services independently
Ensure positive perceptions of adult services
Hamblin, 2011
What care needs to be provided?
Diagnosis
Sexual and
reproductive
health
Transition
support
Independence
from family to
individual
Protection,
care & legal
support
ART
initiation
Care for evolving
adolescent health
needs
Entry to care
for ALHIV
Adherence
advice
Adolescent
health and
wellbeing
ART initiation
and retention
Coping with
illness and
long-term care
Psychosocial
wellbeing
Disclosure
Stigma &
discrimination
Mental health
1. Hamblin, 2011; 2. AIDStar-One, 2012
Different models for transition
The selected transition model is determined by the
patient, available resources and geographical setting
1
3
Family Clinics:
Integration
2
Specialist Services:
Separate youth clinic
Specialist Services:
Handing over from
paediatric to adult
services
CHIVA Guidance on Transition for Adolescents living with HIV 2011
Treatment
considerations in
younger women
Women for Positive Action is an educational program funded by AbbVie
Clinical considerations in young women
with perinatally vs non-perinatally acquired HIV
Perinatally acquired HIV
•
Non-perinatally acquired HIV
More advanced stages of disease and
immunosuppression
•
Earlier stages of HIV disease
•
Fewer OI complications
•
OI with complications
•
Higher CD4 counts
•
ART more likely to be necessary - high
exposure history
•
Simpler ART regimens on initiation
•
More complicated ART regimens and
multidrug resistant viruses
•
Less likely to be resistant to ART
•
•
Multiple medications
Fewer developmental delays 
improved treatment adherence?
•
Physical and developmental disabilities
 greater dependency on family
•
More likely to achieve functional
autonomy
•
Suboptimal immune response to
immunisations and boosters
OI, opportunistic infections
NY State Department of Health AIDS Institute, 2011
Considerations for treatment choices
in younger women with HIV
Drug / alcohol
use
Drug-drug
interactions
Pregnancy
Contraception /
birth control
Fertility
Co-morbid
conditions
Maximise
efficacy,
safety and
adherence
Drug
resistance
Access and
affordability
Adherence
Treatment
experience
Agwu, 2013
ART in younger women living with HIV
•
Most young women living with perinatally acquired HIV are on ART1
•
Young women with non-perinatally acquired HIV may be initiating ART
for the first time
•
Recommendations for ART initiation in adolescents >13 years old are
often included in adult HIV management guidelines2,3
•
Both adult and paediatric guidelines include remarks about
adolescent patients:
•
•
dosing and management challenges
considering regimens with a higher barrier to resistance given adherence
challenges in adolescents
1. Agwu, 2013; 2. DHHS, Panel on Antiretroviral Guidelines for Adults and Adolescents, 2013; 3. WHO, 2013
Treatment as prevention
•
ART can prevent transmission of HIV from a
woman living with HIV to a HIV-negative
partner, by suppressing viral replication1
•
ART is recommended for HIV-positive partners
in serodiscordant couples, regardless of CD4
count2
•
In 2011, the HTPN 052 Study showed that early
ART reduces the risk of women with HIV
transmitting the disease by 96%3
1. Anglemyer, 2013; 2. WHO, 2013; 3. Cohen, 2011
Resistance to ART drugs is high in
young women living with PAH
Treatment failure in young people during ART is
frequent, develops fast and with more extensive
drug resistance than in adults
Long exposure to older, less
efficacious treatments
Variable levels of
adherence to treatment
Many regimen switches due to:
• Therapeutic failure
• New drugs becoming available
PAH, perinatally acquired HIV
de Mulder, 2012
There are many barriers to adherence
in young women with HIV
Barriers to adherence
are similar in young
people with PAH and NPAH, however, those
with PAH report
significantly more
barriers1
Cognitive
deficits
Feeling well /
complacency
Poor
palatability of
ART
Emotional and
behavioural
issues
Low outcome
expectancy
Adverse effects
of ART
Late or early
responsibility
for own
medicines
Poor
relationships
with medical
providers
Regime
complexity
Fear of
disclosure
Poor
relationships
with parents/
caregivers
Perceived lack
of self efficacy/
control over life
events
Lifestyle
factors
Poor treatment
knowledge and
understanding
1. MacDonell, 2013; 2. Nichols et al, 2012; 3. Agwu, 2013
Feeling well / complacency
Overcoming the challenges of
adherence in younger women
Important to make medication adherence as user
friendly as possible for young women
ART Strategies
• OD regimens for TN
women
• Switching TE patients
receiving complex or
poorly tolerated
regimens to OD
regimens
• Fixed-dose
combinations to
decrease pill burden
Adherence tools
• Reminder devices with
an interactive
component e.g. mobile
phone
OD, once daily; TN, treatment-naive; TE, treatment-experienced
Education and
counselling
interventions
• 1:1 ART education
• 1:1 adherence support
through counselling
• Group education
• Multidisciplinary
education
• Peer support
Thompson, 2012
Medical complications associated with
long-term HIV and/or ART in young women
Metabolic
complications1
Decreased
bone mass
density5
Cognitive
deficits3
Increased
cardiovascular
risk2
Psychiatric
symptoms4
Chronic lung
disease7
Kidney
disease6
1. Barlow-Mosha, 2013; 2. Lipshultz, 2013; 3. Laughton, 2013; 4. Mellins, 2013;
5. Puthanakit, 2013; 6. Bhimma, 2013; 7. Webere, 2013
Strategies to help reduce risks of
medical complications
Bone health1-3
 Weight-bearing exercise
 Adequate dietary calcium intake /
vitamin D supplements
 Avoidance of smoking and excess
alcohol
 Avoidance of ART related to
increased BMD loss
CV health1,4
 Smoking cessation
 Diabetes control
 Control of hypertension
 Physical activity / exercise
 Diet and cholesterol management  Management of depression
1. Lee, 2006; 2. National Osteoporosis Society; 3. Lima, 2011; 4. Lichtman, 2008
Strategies to help reduce risks of
medical complications
Renal health1
 Regular renal function monitoring
 Treat diabetes, dyslipidaemia, hypertension
Preserving cognitive function2,3
 Healthy diet
 Vitamin D3 supplementation
 Exercise
 Stress management: meditation, yoga
 Smoking cessation
 Sufficient sleep
 Group interventions
 Cognitive rehabilitation4
 Home stimulation programmes (cognitive enrichment and mental activity)5
1. Maggi, 2012; 2. Atkinson, 2010; 3. Levy, 2007; 4.Laughton, 2013; 5. Potterton, 2010
Healthy lifestyle choices are important
•
•
As women with HIV live longer, they are at risk of
premature ageing and its associated medical
complications
Adoption of healthy lifestyle choices are essential if young
women living with HIV are to be exposed to potential
lifelong treatment toxicities that can compound this risk
http://www.poz.com/pdfs/Focus_Long_Term.pdf
Emotional health
Women for Positive Action is an educational program funded by AbbVie
Young women with PAH are at high
risk for emotional health problems
>60% of adolescents with PAH show evidence of a clinical mental health
disorder, including depression, anxiety, impulsivity and PTSD1
Better mental health outcomes are
associated with:
• Parent-child communication
• Peer, parent and teacher social support
Worse mental health outcomes are
associated with:
• Stressful life events
• Reduced cognitive function
• Parental psychiatric and substance
abuse disorders
• Loss of a parent
PAH, perinatally acquired HIV; PTSD, post-traumatic stress disorder
1. Mellins, 2009; 2. Mellins, 2013
Young women with PAH are at high
risk for emotional health problems
Data from major US cohort studies of young people with PAH have
demonstrated high levels of mental health disorders
Population of PAH
youth (age)
Disorder prevalence
274 (2-17 years)
52% with ≥1 behavioural problem
Mellins, 2009
206 (9-16 years)
61% with ≥1 psychiatric disorder
Mellins, 2012
166 (6-17 years)
60% with ≥1 psychiatric disorder. Anxiety disorders most prevalent
Elkington, 2011
196 (9-16 years)
Higher likelihood of depression vs. HIV negative
197 (13-24 years)
55% with ≥1 psychiatric diagnosis
Gadow, 2010
319 (6-17 years)
61% with ≥1 psychiatric diagnosis
Williams, 2010
196 (12-18 years)
11% depression; 14% substance abuse
Gadow, 2012
319 (6-17 years)
69% with ≥1 psychiatric diagnosis
Nachman, 2012
319 (6-17 years)
33% with ≥1 psychiatric diagnosis
Study
PACTG
Nozyce, 2006
CASAH
LEGACY
Kapetanovic, 2011
IMPAACT
PAH, perinatally acquired HIV
Mellins, 2013
Free access to appropriate HIV treatment
and care may reduce risk of emotional
health disorders
•
Although young women living with HIV may be at risk of emotional health
problems, a recent large Spanish study reported that this risk is not dissimilar
to that in uninfected young women when there is free access to HIV
treatment and care
EVhA-1 Study
• Epidemiological case-control,
comparative, cross-sectional
study
• April-November 2011
• 14 national sites
• Women aged ≥ 16 to ≤ 22
years
• 46 matched-pairs
• Women with HIV were
clinically stable
Galindo, 2013
Drug and alcohol use is common in
young women living with HIV
•
•
Drug and alcohol use is more frequent among young people with
N-PAH vs. PAH1
Individuals with CD4 lymphocyte % <25% have a significantly
increased risk of substance use2
PAH
N-PAH
PAH, perinatally acquired HIV; N-PAH, non-perinatally acquired HIV
1. Conner, 2013; 2. Williams, 2010
Addressing challenges associated with
alcohol/drug use in young women with HIV
Address intimate partner violence
Provide alternative adaptive coping strategies
Manage depression
Support through traumatic life-events
Create environments that empower young people
not to drink or use other drugs
Provide targeted, gender-specific education about
the risks of drug abuse and excessive drinking
Wells, 2008
Stigma and disclosure
Women for Positive Action is an educational program funded by AbbVie
The challenges of disclosure in young
women with perinatally acquired HIV
Family pressure to maintain diagnosis secrecy
Difficult decisions and conversations, such as explaining school
absence, taking medication and coping with physical changes
May disclose to fewer friends than their counterparts with N-PAH
Skipping doses and hiding their medication for fear friends or
family might discover their serostatus is frequently reported
PAH, perinatally acquired HIV; N-PAH, non-perinatally acquired HIV
Calabrese, 2012
The pros and cons of disclosure for
young women
Fears around disclosure
• May also be a disclosure of sexual activity
• Risk of isolation from peer groups
• Fear of abandonment, loss of economic
security and accusations of infidelity
• Fear of violence
• Desire to retain moral integrity and status
• Discrimination
The benefits of disclosure
• Improved emotional wellbeing and fewer
symptoms of depression
• Less anxiety
• Increased social support, acceptance
• No need to hide treatment
• Easier to plan for the future, discuss prevention
Rujumba, 2012
Initiatives to help support young women
who decide to disclose their HIV status
Policy and programme
approaches
Counselling
approaches
• Training healthcare
workers in HIV
management
• Ongoing counselling
and HIV support
groups
• Establishing VCT
services
• Mediated disclosure
• Reforming laws on
discrimination and
confidentiality
• Involving women in
HIV testing and
counselling
Community-based
initiatives
• Promoting tolerance
and compassion
through
‒ Public information
campaigns
‒ Community forums
Peer Support
VCT = Voluntary Counselling and Testing
WHO, 2004
Existing peer support initiatives for
women living with HIV
Sexual and
reproductive health
issues
Women for Positive Action is an educational program funded by AbbVie
Sexually transmitted diseases in
young women living with HIV
• Leads to increased rates of HIV transmission1
STIs are
frequent in
young
women living
with HIV2,3
• Vaginal infections, including bacterial vaginosis
and trichomonas vaginalis (TV), are particularly
common4
• Uptake of screening is often low following HIV
diagnosis in young women with N-PAH3
• Screening for STIs e.g. HSV2, should be
conducted routinely
• Safe sexual practices should be encouraged
N-PAH, non-perinatally acquired HIV
HSV-2, Herpes simplex virus-2
1. Ward, 2010; 2. Grant, 2006; 3. Hughes, 2013; 4. Gatski, 2011
Sexual health in young women living
with HIV
Perinatally
acquired
Non-perinatally
acquired
• Later onset of sexual debut compared to those living
without HIV1
• High rate of unprotected sex (>60%)2
• Sexually active girls are less likely to be on ART than
non-sexually active girls3
• More likely to be sexually active than those with PAH2
• More likely to have been diagnosed with an STI2
– At HIV diagnosis, >25% of those with N-PAH have
concurrent STIs4,5
PAH, perinatally acquired HIV; N-PAH, non-perinatally acquired HIV
1. Mellins, 2011; 2. Setse, 2011; 3. Brogly, 2007;
4. Grant, 2006; 5. Hughes, 2013
Sexual risk behaviour is high among
perinatally infected young women
As young women with
PAH become sexually
active, they may
place their partners
at risk for HIV
In a US study of young people with
PAH aged 10-18 years:
•
•
•
•
Effective interventions to
facilitate adherence,
safe sex practices, and
disclosure are urgently
needed
PAH, perinatally acquired HIV
•
•
28% reported sexual intercourse (median
initiation age, 14 years)
62% reported unprotected sex
ART non-adherence was associated with
sexual initiation
Only 33% disclosed their HIV status to
their first sexual partner
42% of sexually active young people had
HIV RNA ≥5000 copies/mL after sexual
initiation
Viral drug resistance was high
Tassiopoulos, 2013
Cervical abnormalities are high in
young women living with HIV
Young women living with HIV are
predisposed to cervical disease
Cervical intraepithelial neoplasia (CIN) - the
precursor lesion for cervical cancer - is more
common and more likely to recur in women
living with HIV
Evidence suggests
that cervical cancer is
more common in
these women
PAH, perinatally acquired HIV;
N-PAH, non-perinatally acquired HIV
The rate of cervical
abnormalities is higher
in women with N-PAH
vs. PAH1
Recurrence rates for
CIN in WLWH have
been estimated to be
as high as 56% and
up to 87% in severely
immunocompromised
women2,3
1. Brogly, 2007; 2. Fruchter, 1996; 3. Wright, 1994
Human papillomavirus infection (HPV)
in younger women with HIV
It is estimated that 12% of women
with normal cervical cytology have
HPV worldwide1
•
Prevalence
• Sub-Saharan Africa = 24%
• Europe = 14%
Prevalence is 3-times higher in
women living with HIV compared
with women living without HIV2
HIV can lead to cervical high-grade
squamous intraepithelial lesions and
cervical cancer3,4
High-risk HPV can cause
intraepithelial neoplasia or the
anogenital region including cervical
and anal cancers5,6
Prevalence peaks before 25 years,
then decreases progressively1
Low-risk HPV can cause cervix
abnormalities and anogenital
warts5,6
1. Bruni, 2010; 2. Konopnicki, 2013; 3. Ahdieh, 2001; 4. Palefsky, 2003; 5. Flowers L & Gattoc LP. Contemporary OB/GYN 2012
6. Hariri S et al. VPD Surveillance Manual, 5th Edition, 2011. Human Papillpmavirus: Chapter 5-1
Cervical screening guidelines
Women living with HIV should receive regular cervical
cancer screening, but in many countries uptake is low
HIV guidelines recommend that providers:
Include cervical cytology (Pap smear) with initial colposcopy as
part of initial evaluation
Repeat cervical smear annually thereafter
Refer immediately to specialist colposcopy services following an
initial abnormal smear
Screen women with the same age range as HIV-negative women,
i.e. 25–65 years old
•
Monitoring on a case-by-case basis is necessary for sexually active adolescents
who may have been immunosuppressed for many years
BHIVA, 2011
How can cervical cancer screening be
improved?
Dual approach
Education
Healthcare professionals:
Screening all women with HIV,
especially 1) of increasing age, 2) with
low CD4 counts, and 3) who receive
Pap tests elsewhere
Primary care providers and
gynaecologists: Difference in
screening recommendations for
WLWH
Women living with HIV:
Recommendations for annual Pap
testing
System change
Integrate HIV care and
gynaecologic care
Increased
cervical cancer
screening
Human papillomavirus (HPV) vaccine
for young women with HIV
The HPV vaccine is effective and well tolerated in young
women with HIV1
Despite having already been exposed to HPV there may be a
benefit from vaccination1
Several HIV guidelines recommend HPV vaccination for all
young women with HIV, up to age 26 years2,3
Young women living with HIV may also be infected with
atypical HPV types 52 and 58, which are high-risk but not
protected by the current vaccines4
1. Kahn, 2013; 2. ACIP; 3. www.hivguidelines.org; 4. Blackman, 2013
Unplanned pregnancy
•
•
Often occur in young WLWH1,2
Young women with PAH are becoming sexually active and having
children of their own
Pregnancy rate in young women with
N-PAH is:
• 5 times that in the general
population aged 15-191
•
Maternal viral load is detectable
close to delivery in 33% of
pregnancies in young women
with PAH2
Early risk reduction to prevent unplanned pregnancies among young
women with HIV is critical
Timely management is required in this population of young women for
pregnancy care and prevention of onward transmission
PAH, perinatally acquired HIV; N-PAH, non-perinatally acquired HIV;
WLWH, women living with HIV
1. Agwu, 2011; 2. Kenny, 2012
Pregnancy differences between young
women with perinatally and non-perinatally
acquired HIV
Perinatally
acquired
(n=130)
Non-perinatally
acquired
(n=51)
21.5%
74.5%
52.3
372.9
% of young women with >1 pregnancy
14.3%
36.8%
CD4<200 cells/mm3 as pre-pregnancy
nadir
35.7%
7.5%
CD4<200 cells/mm3 at delivery
28.6%
5.0%
% of pregnancies ending in spontaneous abortion
5.9%
17.7%
% of young women undergoing elective
termination
41.2%
9.7%
% of young women with ≥1 pregnancy
Pregnancy incidence rates
(per 1000 patient-years)
Agwu, 2011
The challenges of pregnancy in
women with perinatally acquired HIV
The management of
pregnancies in young
women with PAH is
complicated by:1,2
• extensive ART experience
• the presence of multidrugresistant virus
• history of suboptimal
adherence
• limited therapeutic options
• psychosocial issues
• high risk of STIs
Pregnant women with
PAH may be at a
higher risk for HIV
progression and this
may increase risk of
vertical transmission1
Current data report
comparable risk of
MTCT between
PAH and N-PAH
PAH, perinatally acquired HIV; N-PAH, non-perinatally
acquired HIV; MTCT, mother to child transmission; VL, viral load
Compared with women
with N-PAH, pregnant
women with PAH:1,2
• have significantly lower
median CD4 counts
• have significantly higher VL
• are less likely to achieve
undetectable VL at delivery
• are significantly more likely
to have caesarean section
• have an increased risk of
preterm births
• are more likely to have
persistent viral replication in
the post-partum period
1. Phillips, 2011; 2. Badell, 2012
Reproductive counselling in young
women living with HIV is critical
Safe and effective reproductive health and
contraceptive services are an essential
component of care for WLWH and of
In a US
childbearing age to reduce:
study of WLWH:
- unplanned pregnancy
• 48% of women who were
- perinatal HIV
or had been pregnant had never
transmission
been asked by their HCP if they were
considering pregnancy
• 57% of women who had been or were
thinking about getting pregnant had not discussed
appropriate treatment options with their HCP
WLWH, women living with HIV
Squires, 2011
Routine and ongoing pre-conception
counselling for WLWH of childbearing age
Effective
contraception
Use of ARTs
and other drugs
in pregnancy
Maternal
reproductive
health issues
Safe
conception
Impact of
pregnancy
on HIV
Long-term
health of
mother and
ability to care
for children
Impact of HIV
on pregnancy
Psychosocial
issues,
postpartum
impact on
adherence and
outpatient visits
Mother-to-child
transmission
Importance of
early and
intense
antenatal care
Hoyt, 2012
The ideal contraceptive for younger
women living with HIV
Reliable
Safe
Convenient
Reversible
Prevent transmission of HIV
Not interfere with HAART
Affordable
. . . . currently means it must involve condoms
Contraception options in HIV
Method
Advantages
Disadvantages
• Pregnancy prevention = 85% male;
• STI/HIV protection
• Female condom can be controlled by
Condoms
(male and female)
woman
•
•
•
•
79% female
Cooperation needed
Requires correct technique
Inconvenient / may interfere with
sexual intercourse
Price/availability of female condom
Oral contraceptive pill
(OCP)
• Effective
• Less blood loss
• Pregnancy prevention = 92%
• Drug-drug interactions
• Possibly  viral shedding
• No STI/HIV protection
Patch, ring, combo
injectable
• Effective
• Less blood loss
• Pregnancy prevention = 92%
•
•
•
•
• Possible increased risk of HIV
DMPA
• Low maintenance
• Effective
• Pregnancy prevention = 97%
Drug-drug interactions?
Lack of data
 shedding?
No STI/HIV protection
acquisition
• No STI/HIV protection
1. Mostad et al. Lancet 1997; 2. Trussell, Contraceptive Technology 2007; 3. Wang et al. AIDS 2004
Contraception options in HIV
Method
Advantages
Disadvantages
Copper intra-uterine
device (IUD)
• Convenient
• Effective
• Pregnancy prevention = 99.2%
• Blood loss
• No STI/HIV protection
Levonorgestrelreleasing intrauterine
system
• Long lasting
• Convenient
• Pregnancy prevention = 99.8%
• Reduced blood loss
• No STI/HIV protection
• Minimal research available in HIV
Cervical barrier
• Reusable/low cost
• Effective if used correctly
• Pregnancy prevention = 84%
•  urinary tract infections
• Requires correct technique
• Unproven HIV/STI protection
Sterilisation
• Low maintenance
• Effective
• Pregnancy prevention = 99.5%
• Irreversible, invasive
• Expensive
• No STI/HIV protection
Trussell, Contraceptive Technology 2007
Guidance on the use of hormonal
contraception in women with HIV
“Some studies suggest that women using progestogen-only injectable
contraception may be at increased risk of HIV acquisition, other studies do
not show this association. A WHO expert group reviewed all the available
evidence and agreed that the data were not sufficiently conclusive to change
current guidance. However, because of the inconclusive nature of
the body of evidence on possible increased risk of HIV
acquisition, women using progestogen-only injectable
contraception should be strongly advised to also always use
condoms, male or female, and other HIV preventive measures.
Expansion of contraceptive method mix and further research on the
relationship between hormonal contraception and HIV infection is essential.
These recommendations will be continually reviewed in light of new
evidence"
CDC, 2012
Examples of initiatives
for younger women
Women for Positive Action is an educational program funded by AbbVie
AIMS
Young Women’s Leadership Initiative
Developing the leadership
of young women around
HIV, women’s rights and
gender equality
Increasing visibility and
advocacy of young
women
International skills-building and advocacy activities
designed to strengthen the engagement, capacity and
skills of young women in the HIV response
http://www.womeneurope.net/resources/YoungWomensLeadershipInitiativeRomeIAS2011FINAL.pdf
AIMS
Bring on the Change
To bring community groups,
advocates, activists,
networks and other
stakeholders together
To achieve a more inclusive
and comprehensive HIV
response that takes into
account the voices of young
women
A regional advocacy platform to amplify the voices of
young women affected by drug use and HIV in Eastern
Europe and Central Asia
http://www.hivyoungleadersfund.org/wp-content/uploads/2013/06/IHRC-Call-to-Action_English.pdf
National initiatives for younger women
living with HIV
UK
France
Young People
•
Created in 2003 by and for
families affected by HIV / AIDS
• Provides a network of
information, meetings, support
and campaigning for equal rights
against the disease
• ‘Big Sisters’ project provides
support for women who learn
their HIV status during pregnancy
•
Led by young people living with
HIV
• Topics covered include:
•
•
•
•
•
•
•
•
•
•
http://www.comitedesfamilles.net/
HIV diagnosis
Sexual health
Relationships
Starting a family
Social Services
HIV treatment and adherence
Disclosure
Finance and benefits
Immigration
Housing
http://positivelyuk.org/young-people/#support
Thank you for your
attention
Any questions?
Women for Positive Action is an educational program funded by AbbVie