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P.S. Reichelderfer, PhD
Harwood, Maryland
WHIN Meeting, 2005
Fertility Regulation Update
Fertility Regulation Update
Historical Perspective
• January 2003 Meeting “Fertility Regulation and Systemic Hormones in HIVinfected and At-risk Women”
– Contraceptive choices for HIV-infected and at-risk women
– Hormonal influences on HIV acquisition
– Hormonal influence on HIV disease and co-morbidities
– Hormonal influence on treatment and the effect of treatments on
contraceptive methods
– Hormonal influence on changes in genital tract virological/immunological
parameters and implications for transmission
– What is the role of artificial insemination in HIV-discordant couples?
– What is the role of hormonal menopausal therapy in HIV-infected and at-risk
women?
Contraceptive Choices
• Developing world
– Depo-Provera is the most commonly used
– Stigma associated with birth control of any type is the
major issue
• Developed world
– Oral Contraceptives
– Interaction with HIV therapeutic drugs is the major
issue
Hormonal Influences on HIV Acquisition
• Multivariate and ongoing analysis suggest
contraceptive use both inject able and oral
increase HIV acquisition
• “HCARAT” a prospective trial of HIV acquisition
and hormonal use suggests ? (check the Lancet
website at the end of the month).
Hormonal Influence on Treatment and the Effect of
Treatment on Hormonal Methods
• There appears to be more rapid disease
progression with women on contraceptives
primarily due to selection of more
“virulent/multiple strains” of virus during acute
infection
• Treatment with drugs that are metabolized
through the same cytochrome system as the
contraceptive is contraindicated
Hormonal Influences on Genital Tract Parameters
• Shedding of virus in the genital tract (when it
occurs) appears to be hormonally regulated
• Cytokines in the genital tract appear to be
hormonally regulated
• Chemokine receptors (R5) appear to be up
regulated by exogenous hormones
Artificial Insemination in Discordant Couples
• The major issue in the developing world is the
stigma associated with a women who does not
have children
• There is no incentive for male cooperation in
volunteer counseling and testing for HIV
• In the developed world, the major issue is
prejudice on the part of society in general and
health care providers specifically
Role of Menopausal Therapy
• The major issue is that in applying the results of
the large study on “normal” menopausal women
we may overlook the impact on HIV-infected
women, but doing the trials will be problematic
from an IRB standpoint
Here and Now
• Update from the AIDS Clinical Trials Group on
what they have been doing in the area of fertility
regulation
• Discussion on assisted reproductive technology –
leading to protocols/RO1s/RFAs/RFCs?
• On with the show!
Future Research Directions 03
• Conduct epidemiological studies on contraceptive
use and needs in HIV-infected and at-risk women
nationally, internationally, married and single and
throughout the life cycle.
• Promote multidisciplinary studies integrating
family planning and infectious disease expertise
(training grants).
Future Research Directions 03 cont.
• Analyze ongoing studies on hormonal
contraceptive disease acquisition and progression,
and define future research based on these studies.
• Integrate studies on gender and ethnicity in
clinical trials to elucidate the role of hormones
versus genetics on therapy and disease course.
Future Research Directions 03 cont.
• Increase measurement studies of virological and
immunological parameters in the genital tract in
all clinical studies.
• Define potential studies to address the feasibility
of assisted reproductive technology in
serodiscordant couples, and the potential
risk/benefit of hormonal therapy in HIV-infected
women.