Shannon Weber

PrEP as Peri-conception HIV Prevention for Women and Men

Daily oral tenofovir (TDF)-based pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy and recommended for men and women with substantial risk of HIV acquisition. The peri-conception period, the stage prior to pregnancy when condom use is necessarily reduced, has elevated HIV risk that can be mitigated by PrEP use. Data from a randomized trial suggest that peri-conception PrEP use by HIV-seronegative women does not increase the risk of pregnancy loss, birth defects or congenital anomalies, preterm birth, or infant growth faltering. Women considering PrEP use throughout pregnancy must weigh the known increased risk of HIV acquisition with unknown risks of drug effects on infant growth. PrEP has been used safely by HIV-seronegative men with HIV-seropositive female partners who have become pregnant. As an effective user-controlled HIV prevention strategy, PrEP offers autonomy and empowerment for HIV prevention and can be recommended alongside antiretroviral therapy, fertility screening, vaginal self-insemination, intercourse timed to peak fertility, medically assisted reproduction, and other safer conception strategies to provide multiple options. The integration of PrEP into safer conception programs is warranted and will safely reduce HIV transmission to women, men, and children during the peri-conception period.

Assisted reproduction for couples affected by human immunodeficiency virus in California

Survey results demonstrate that the majority of fertility clinics in California are willing to care for couples affected by human immunodeficiency virus (HIV) if legal restrictions are removed. In response to scientific advances and evolving clinical standards, California reversed the limitations placed on the provision of assisted reproduction for HIV-positive men in 2008.

Breastfeeding and HIV-Infected Women in the United States: Harm Reduction Counseling Strategies

Social and cultural forces have led some human immunodeficiency virus (HIV)-infected women to question the recommendation in the United States not to breastfeed. Without an open dialogue, women may choose to breastfeed exclusively or intermittently and not disclose this to their provider. We review the evidence from global studies of the risks of breastfeeding among HIV-infected mothers and propose a harm reduction model for women considering breastfeeding.

Safer conception options for HIV serodifferent couples in the United States: the experience of the National Perinatal HIV Hotline and Clinicians' Network.

To the Editors: Over half of HIV-positive adults in heterosexual partnerships in the United States report having an HIV-negative partner. Moreover, the Centers for Disease Control and Prevention estimate approximately half of the 140,000 heterosexual serodifferent couples in the United States desire children. The largest population-based study of heterosexual HIV-infected adults in the United States found 29% of HIV-positive women desire future fertility compared with 36% of reproductive-aged women in the general US population. Other studies indicate that 59% of HIV-positive women engaged in care in the United States expressed a desire for children, with this proportion increasing to 80% among HIV-positive young women. The only published study evaluating the fertility desires of HIV-positive heterosexual men in the United States reported that 28% wanted children. Given HIVaffected couples’ desires to have children, services focusing on safer conception, supportive of reproductive health decision making, are urgently needed. For HIV-positive female/HIVnegative male serodifferent couples, home insemination using ejaculated semen is a low-cost intervention posing no risk of HIV transmission to the HIV-negative male partner, assuming that the couples consistently use condoms. However, HIV-positive male/HIV-negative female couples who desire conception contend with the issue of HIV infectivity of semen. There are several safer conception interventions for HIV-positive male/HIVnegative female couples including assisted reproductive technologies (such as intrauterine insemination or in vitro fertilization) with donated or washed sperm, timed intercourse with suppressive antiretroviral therapy for the infected man with or without pre-exposure prophylaxis to the uninfected woman, or adoption. However, couples and their health care providers may not be aware of the range of options available to reduce the risk of HIV transmission to the uninfected partner during conception attempts. Furthermore, even when couples are informed of the options, they may lack access, because of cost or location, to assisted reproduction technologies, such as sperm washing and in vitro fertilization. Little is known about the knowledge gaps and referral needs of clinicians and HIV serodifferent couples regarding conception options. To better understand these needs, we sought to evaluate the types of calls made to the National Perinatal HIV Hotline and Clinicians’ Network related to conception for HIV-affected couples. The National Perinatal HIV Hotline and Clinicians’ Network is a Health Resources and Services Administrationfunded initiative operated by the University of California, San Francisco Department of Family and Community Medicine at the San Francisco General Hospital. The National Perinatal HIV Hotline provides free 24-hour consultation for US clinicians on HIV care from preconception through pregnancy and birth. Additionally, HIV-positive pregnant women and their exposed infants are referred to local experts for care through the Perinatal HIV Clinicians’ Network that includes over 300 providers nationwide. Calls to the National Perinatal HIV Hotline are entered in a centralized database including caller demographics and call details. For this analysis, we evaluated all calls to the National Perinatal HIV Hotline and referrals to the Perinatal HIV Clinicians’Network between January 1, 2006, and December 31, 2011. Calls pertaining to conception were identified through key word search. We evaluated trends over time in the number of calls related to conception using the extended Mantel–Haenszel x2 test for linear trend. We categorized calls by the direction of serodifference in the couple and the types of questions asked. Question types were classified as legal queries, referrals for assisted reproduction, and requests for nonassisted conception options. During the study time period, there were 2183 total calls and 246 total referrals to the National Perinatal HIV Hotline and Clinicians’ Network. Of these 2429 calls and referrals, 152 (6.3%) regarded conception for serodifferent couples: 68 (45%) from patients and 84 (55%) from clinicians. Total call volume increased over time with a statistically significant increase in the number of calls related to conception for HIV-affected couples (P value for trend , 0.001, Fig.

Integrating Preexposure Prophylaxis for Human Immunodeficiency Virus Prevention Into Womenʼs Health Care in the United States

Women comprise one in five new human immunodeficiency virus (HIV) diagnoses in the United States. Trials and implementation projects demonstrate preexposure prophylaxis for HIV prevention is effective in women. Preexposure prophylaxis is a method of preventing HIV acquisition by having an HIV-negative individual take antiretroviral medication before exposure. The U.S. Food and Drug Administration approved daily oral tenofovir disoproxil fumarate coformulated with emtricitabine as preexposure prophylaxis for HIV prevention in 2012. Preexposure prophylaxis is highly dependent on adherence for effectiveness. The Centers for Disease Control and Prevention recommends offering preexposure prophylaxis to individuals at significant risk of infection and estimates 468,000 women in the United States are eligible for preexposure prophylaxis. Although variable individual and structural forces affect each womans medication adherence, and therefore the effectiveness of preexposure prophylaxis, womens health care providers are uniquely positioned to screen, counsel about, and offer preexposure prophylaxis. Shared decision-making provides a framework for these clinical encounters, allowing patients and clinicians to make health care decisions together based on scientific evidence and patient experiences. By incorporating fertility desires and contraceptive needs, health care providers effectively integrate sexual and reproductive health care. Including preexposure prophylaxis in womens health services requires health care provider training and attention to lessons learned from family planning and HIV prevention. Nevertheless, obstetrician-gynecologists have an opportunity to play a critical role in reducing sexual transmission of HIV in the United States by integrating preexposure prophylaxis education and provision into their practices.

Consensus statement: supporting safer conception and pregnancy for men and women living with and affected by HIV

Safer conception interventions reduce HIV incidence while supporting the reproductive goals of people living with or affected by HIV. We developed a consensus statement to address demand, summarize science, identify information gaps, outline research and policy priorities, and advocate for safer conception services. This statement emerged from a process incorporating consultation from meetings, literature, and key stakeholders. Three co-authors developed an outline which was discussed and modified with co-authors, working group members, and additional clinical, policy, and community experts in safer conception, HIV, and fertility. Co-authors and working group members developed and approved the final manuscript. Consensus across themes of demand, safer conception strategies, and implementation were identified. There is demand for safer conception services. Access is limited by stigma towards PLWH having children and limits to provider knowledge. Efficacy, effectiveness, safety, and acceptability data support a range of safer conception strategies including ART, PrEP, limiting condomless sex to peak fertility, home insemination, male circumcision, STI treatment, couples-based HIV testing, semen processing, and fertility care. Lack of guidelines and training limit implementation. Key outstanding questions within each theme are identified. Consumer demand, scientific data, and global goals to reduce HIV incidence support safer conception service implementation. We recommend that providers offer services to HIV-affected men and women, and program administrators integrate safer conception care into HIV and reproductive health programs. Answers to outstanding questions will refine services but should not hinder steps to empower people to adopt safer conception strategies to meet reproductive goals.

Pre-Exposure Prophylaxis (PrEP) for Safer Conception Among Serodifferent Couples: Findings from Healthcare Providers Serving Patients with HIV in Seven US Cities

Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV transmission among serodifferent couples trying to conceive, yet provider knowledge, attitudes, and experience utilizing PrEP for this purpose are largely unexamined. Trained interviewers conducted phone interviews with healthcare providers treating patients with HIV in seven cities (Atlanta, Baltimore, Houston, Kansas City, Newark, Philadelphia, and San Francisco, N = 85 total). Quantitative and qualitative data were analyzed to describe experience, concerns, and perceived barriers to prescribing PrEP for safer conception. Providers (67.1% female, 43 mean years of age, 70.4% white, 10 mean years treating HIV+ patients, 56% in academic vs. community facilities, 62.2% MD) discussed both benefits and concerns of PrEP for safer conception among serodifferent couples. Only 18.8% of providers reported experience prescribing PrEP, 74.2% were willing to prescribe it under ideal circumstances, and 7.0% were not comfortable prescribing PrEP. Benefits included added protection and a greater sense of control for the HIV-negative partner. Concerns were categorized as clinical, system-level, cost, or behavioral. Significant differences in provider characteristics existed across sites, but experience with PrEP for safer conception did not, p = 0.14. Despite limited experience, most providers were open to recommending PrEP for safer conception as long as patients understood the range of concerns and could make informed decisions. Strategies to identify and link serodifferent couples to PrEP services and clinical guidance specific to PrEP for safer conception are needed.

“I have it just like you do”: voices of HIV-negative partners in serodifferent relationships receiving primary care at a public clinic in San Francisco

HIV transmission among serodifferent couples has a significant impact on incidence of HIV worldwide. Antiretroviral interventions (i.e., preexposure prophylaxis, post-exposure prophylaxis, and treatment as prevention) are important aspects of comprehensive prevention and care for serodifferent couples. In this study, HIV-negative members of serodifferent couples were interviewed using open-ended questions to explore their health-care needs, perceptions of clinic-based prevention services, and experience of having an HIV-infected partner. Analysis of interviews with 10 HIV-negative partners revealed the following themes: (1) health needs during joint medical visits; (2) sexual risk reduction strategies; (3) relationship dynamics; and (4) strategies for coping. This study elucidated relationship, health and health care factors that might affect development and implementation of clinic-based prevention interventions for HIV serodifferent couples. The findings point to possible relationship-centered recommendations for health-care providers who serve HIV-affected couples in clinical settings.

“Is It All Right for Me to Have a Baby or Not?”: Men Living With HIV Discuss Fertility Desires and Interactions With Providers

&NA; To our knowledge, no study in the United States has qualitatively examined fertility desires, experiences communicating with health care providers about sexual and reproductive health, and attitudes toward reproductive counseling and services in men living with HIV (MLWH) who have sex with women. We conducted focus groups and interviews with MLWH (N = 17) who have sex with women seeking HIV care in San Francisco. The men conveyed limited awareness of safer conception strategies. While many men expressed the desire to have a child, most reported that their providers had not discussed reproduction with them. Participants highlighted the lack of HIV services for men who have sex with women and the need for improved reproductive counseling. We make recommendations for providers who work with MLWH who have sex with women and for patient‐centered materials on safer conception, sexual HIV transmission risk reduction, and family planning strategies.

CDC should reverse its recommendation against semen washing-intrauterine insemination for HIV-serodifferent couples

CDC Should Reverse Its Recommendation against Semen Washing-IntrauterineInsemination for HIV-serodifferent CouplesDeborah Cohan, MD, MPH Shannon Weber, MSW Erika Aaron, MSN, CRNPPII: S0002-9378(13)00406-7DOI: 10.1016/j.ajog.2013.04.031Reference: YMOB 9251To appear in: American Journal of Obstetrics and GynecologyReceived Date: 27 March 2013Accepted Date: 24 April 2013Please cite this article as: Cohan D, Weber S, Aaron E, CDC Should Reverse Its Recommendationagainst Semen Washing-Intrauterine Insemination for HIV-serodifferent Couples, American Journal ofObstetrics and Gynecology (2013), doi: 10.1016/j.ajog.2013.04.031.This is a PDF file of an unedited manuscript that has been accepted for publication. As a service toour customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain.