Preconception Care for HIV-Infected Women: Guideline and Commentary

Preconception Care for HIV-Infected Women: Expert Commentary

Pregnancy always involves decisions: "Do I want to have a baby and is this the best time in my life?" "Am I with a supportive partner?" "Am I, and is my partner, in optimal health to support a family?" These are questions that women ask of themselves and their care providers and in particular, these are questions women ask if they have a health condition.

Pregnancy may be planned or not. The mother may be healthy only to have a genetic predisposition or illness uncovered in the course of prenatal care. Or a woman with a transmissible condition like HIV may decide to become pregnant and ask what she can do to protect the baby from infection. These are the challenges that face those who care for women, especially women who are HIV-seropositive.

Standard of care practice has evolved over the past 15 years on the foundation of the initial findings in 1994 that azidothymidine (AZT) use in pregnancy dramatically decreased the likelihood of maternal to child transmission (MTCT). Antiretroviral (ARV) medications, coupled with consideration of elective C-section under certain conditions, has resulted in MTCT rates < 1% when the viral load is optimally suppressed. Thus the role of early maternal HIV detection and prevention of MTCT through preconception and antepartum counseling assumes central importance.

The New York State Department of Health AIDS Institute has released the document on Preconception Care for HIV-infected Women ¹ (see next page) to guide women and care providers in this decision-making process. It is appropriate that the document begins with an emphasis on contraception in the context of options counseling, on prevention of sexually transmitted infection (STI) and HIV transmission, and on health promotion for all women of reproductive age. However, for this message to engage the patient, it is vital that the dialogue with the healthcare provider be respectful and consider the context of the patient's life and that of her defined family. A general question about the possible impact of a pregnancy, asked in an open-ended manner, can facilitate an honest discussion that reveals and clarifies a patient's values, which is central to both family planning and options counseling decisions. In choosing a contraceptive method, it is essential to recognize the adverse drug interactions with ARV medications that can have an impact on the effectiveness of hormonal contraceptive medications.

Despite appropriate counseling and best intentions, unintended pregnancy rates remain high in the United States, including in HIV-positive women.² Therefore, a regular review of ARV medications, with avoidance of those that are contraindicated in pregnancy, is crucial. For patients who decide to maintain a pregnancy, an informed decision, weighing risks and benefits of ARV, is vital. Collaboration with obstetrical services can assure appropriate prenatal care and suppression of the viral load. Care providers should also be aware of regional referral services should the patient choose to terminate the pregnancy.

Effective medical treatment of HIV infection has changed the way women live their lives. They may choose to become pregnant with the knowledge that they are very likely to have a child who is not infected with HIV. Care providers of these patients assume a key role in coordinating medical, dental, and mental health services. Equally important is finding the key to the patient's acceptance of treatment for her sake and that of her unborn child.

References

Women's Health Committee. Preconception Care for HIV-infected Women. New York State Department of Health AIDS Institute. July 2010. Available at https://www.hivguidelines.org/clinical-guidelines/womens-health/preconception-care-for-hiv-infected-women/ Accessed September 7, 2010.
Massad LS, Springer G, Jacobson L, et al. Pregnancy rates and predictors of conception, miscarriage, and abortion in US women with HIV. AIDS. 2004;18:281-286. Abstract

Table 1. Interactions Between Ethinyl Estradiol and ARVs and Other Drugs
Antiretrovirals
ARV	Effect on Ethinyl Estradiol (EE)	Recommendation
*NNRTIs*
Efavirenz (EFV)	↑ EE 37%	Consider usingalternative form of contraception. Use lowest dose of hormonal contraception and monitor for adverse contraceptive reactions. Consider an alternative ARV in patients not adherent to an oral contraceptive regimen
Etravirine (ETR)	↑ EE AUC 22% ↓ Norethindrone AUC 5%	No dose adjustment needed
Nevirapine (NVP)	↓ EE ~ 20% ↓ Norethindrone	Consider usingalternative or additional forms of contraception
*PIs*
Atazanavir (ATV) Atazanavir/ritonavir (ATV/r)	↑ EE AUC 48% ↑ Norethindrone AUC 110% ↓ EE AUC 19% ↑ Norethindrone metabolite by 85%	• Co-administered with ATV without RTV, OC should contain no more than 30 mcg EE. May ↑ progesterone exposure substantially • Co-administered with ATV/r, OC should contain at least 35 mcg EE • If other OCs are used, use alterative method of nonhormonal contraceptive
Darunavir/r (DRV/r)	↓ EE AUC 44% ↓ Norethindrone AUC 14%	Consider using alternative or additional forms of contraception
Fosamprenavir (FPV)	↑ EE and Norethindrone levels APV levels ↓ 20%	Do not co-administer. Consider using alternative form of contraception
Indinavir (IDV)	↑ Norethindrone 26% ↑ EE 25%	No dosage adjustment necessary
Lopinavir/ritonavir (LPV/r)	↓ EE 42% ↓ Norethindrone AUC 17%	Consider usingalternative or additional forms of contraception
Nelfinavir (NFV)	↓ EE 47% ↓ Norethindrone 18%	Consider using alternative or additional forms of contraception
Ritonavir (RTV)	↓ EE 40%	Consider using alternative or additional forms of contraception
Saquinavir/r (SQV/r)	↓ EE	Consider using alternative or additional forms of contraception
Tipranavir/r (TPV/r)	↓ EE 48% No change in norethindrone AUC	Consider using alternative or additional forms of contraception
*CCR5 blocker*
Maraviroc (MVC)	No significant change in EE or levonorgestrel	Use standard dose
*Other Drugs*
Drug	Effect on EE	Recommendation
Barbiturates	↓ EE	Consider using alternative or additional forms of contraception
Rifampin, rifabutin, griseofulvin, phenytoin, ethotoin, mephenytoin, phenobarbital, primidone, carbamazepine, ethosuximide	↓ EE	Avoid co-administration or use alternative or additional forms of contraception with close monitoring. Use highest dose of hormonal contraception
Ciprofloxacin (fluoroquinolones), penicillins, and cephalosporins	EE may be decreased	Use additional forms of contraception with close monitoring

Table 1. Interactions Between Ethinyl Estradiol and ARVs and Other Drugs

Antiretrovirals

ARV

Effect on Ethinyl Estradiol (EE)

Recommendation

NNRTIs

Efavirenz (EFV)

↑ EE 37%

Consider usingalternative form of contraception. Use lowest dose of hormonal contraception and monitor for adverse contraceptive reactions. Consider an alternative ARV in patients not adherent to an oral contraceptive regimen

Etravirine (ETR)

↑ EE AUC 22%
↓ Norethindrone AUC 5%

No dose adjustment needed

Nevirapine (NVP)

↓ EE ~ 20%
↓ Norethindrone

Consider usingalternative or additional forms of contraception

PIs

Atazanavir (ATV)

Atazanavir/ritonavir (ATV/r)

↑ EE AUC 48%
↑ Norethindrone AUC 110%

↓ EE AUC 19%
↑ Norethindrone metabolite by 85%

• Co-administered with ATV without RTV, OC should contain no more than 30 mcg EE.
May ↑ progesterone exposure substantially

• Co-administered with ATV/r, OC should contain at least 35 mcg EE
• If other OCs are used, use alterative method of nonhormonal contraceptive

Darunavir/r (DRV/r)

↓ EE AUC 44%
↓ Norethindrone AUC 14%

Consider using alternative or additional forms of contraception

Fosamprenavir (FPV)

↑ EE and Norethindrone levels
APV levels ↓ 20%

Do not co-administer. Consider using alternative form of contraception

Indinavir (IDV)

↑ Norethindrone 26%
↑ EE 25%

No dosage adjustment necessary

Lopinavir/ritonavir
(LPV/r)

↓ EE 42%
↓ Norethindrone AUC 17%

Consider usingalternative or additional forms of contraception

Nelfinavir (NFV)

↓ EE 47%
↓ Norethindrone 18%

Consider using alternative or additional forms of contraception

Ritonavir (RTV)

↓ EE 40%

Consider using alternative or additional forms of contraception

Saquinavir/r (SQV/r)

↓ EE

Consider using alternative or additional forms of contraception

Tipranavir/r (TPV/r)

↓ EE 48%
No change in norethindrone AUC

Consider using alternative or additional forms of contraception

CCR5 blocker

Maraviroc (MVC)

No significant change in EE or levonorgestrel

Use standard dose

Other Drugs

Drug

Effect on EE

Recommendation

Barbiturates

↓ EE

Consider using alternative or additional forms of contraception

Rifampin, rifabutin, griseofulvin, phenytoin, ethotoin, mephenytoin, phenobarbital, primidone, carbamazepine, ethosuximide

↓ EE

Avoid co-administration or use alternative or additional forms of contraception with close monitoring. Use highest dose of hormonal contraception

Ciprofloxacin (fluoroquinolones), penicillins, and cephalosporins

EE may be decreased

Use additional forms of contraception with close monitoring

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