A review of reproductive health research, guidelines and related gaps for women living with HIV

Figures & data

Table 1. Conception options for HIV concordant and discordant couples.

HIV- woman and HIV+ man	IUI following sperm washing^Footnotea,Footnoteb,Footnotec Timed natural conception (only at ovulation; if effective viral suppression)^Footnotea,Footnoteb,Footnotec Natural conception (if effective viral suppression)^Footnotea,Footnoteb,Footnotec IVF or ICSI following sperm washing^Footnotea,Footnoteb,Footnotec Insemination of donor sperm at ovulation^Footnotea,Footnoteb,Footnotec PrEP with timed natural conception (only at ovulation; if effective viral suppression)^Footnotea,Footnoteb,Footnotec,Footnoted Adoption^Footnotea,Footnoteb
HIV+ woman and HIV- man	Home artificial insemination with partner's sperm during ovulation^Footnotea,Footnotec Timed natural conception (only at ovulation; if effective viral suppression)^Footnotea,Footnoteb,Footnotec Natural conception (if effective viral suppression)^Footnotea,Footnoteb,Footnotec Assisted reproduction in case of fertility disorders including IUI, IVF, ICSI^Footnotea,Footnoteb,Footnotec PrEP with timed natural conception (only at ovulation; if effective viral suppression)^Footnotea,Footnoteb,Footnotec Adoption^Footnotea,Footnoteb
HIV+ woman and HIV+ man	Timed natural conception (only at ovulation; if effective viral suppression)^Footnotea,Footnoteb,Footnotec Natural conception (if effective viral suppression)^Footnotea,Footnoteb,Footnotec IUI following sperm washing^Footnotea,Footnoteb Insemination of donor sperm at ovulation^Footnotea,Footnoteb Assisted reproduction in case of fertility disorders including IUI, IVF, ICSI^Footnotea,Footnoteb,Footnotec Adoption^Footnotea,Footnoteb

IUI, intrauterine insemination; IVF, in vitro fertilisation; ICSI, intracytoplasmic sperm injection; PrEP, pre-exposure prophylaxis.

^a Loutfy et al. (2012b).

^b Fakoya et al. (2008).

^c DAIG and Österreichische AIDS-Gesellschaft (2011a).

^d Vernazza, Graf, Sonnenberg-Schwan, Geit, and Meurer (2011).

Table 2. Fertility and adoption guidelines in European countries, Canada and the USA.^a

Country	Availability of privately funded assisted reproduction?	Availability of publically funded assisted reproduction?	Is adoption an option?	Availability of guidelines?	Guideline reference
Canada	Yes	Yes^Footnoteb	Yes	Yes	Loutfy et al. (2012b)
Denmark	N/A	Yes	No	Yes	Dansk Fertilitetsselskab (2007)
France	N/A	Yes	Yes	Yes	Prise en charge médicale des personnes vivant avec le VIH – Rapport d'Experts (2010)
Germany/Austria	Yes^Footnotec	Yes^Footnotec	Yes, challenging	Yes	DAIG and Österreichische AIDS-Gesellschaft (2011a)
Italy	Yes^Footnoted	Yes^Footnoted	Yes, challenging	Yes	Ministero della Salute (2011)
Portugal	Yes	Yes^Footnoted	Yes, challenging	No
Romania	Yes^Footnoted	No	Yes, challenging	Yes	Manual pentru ingrijirea copilului infectat cu HIV, Romania, (2004)
Spain	Yes	Yes^Footnoted	Yes, challenging	Yes	Grupo de expertas y expertos del plan nacional sobre el sida y de gesida (2011)
UK	Yes	Yes^Footnoted	Yes, challenging	Yes	Fakoya et al. (2008)
USA	Yes	No	Yes	Yes	The Ethics Committee of the American Society for Reproductive Medicine (2010)

N/A, not applicable.

^a Information included in this table has been collected from Women for Positive Action faculty embers.

^b 3 cycles of IVF are covered in Quebec; 40% fertility tax credit up to $20,000 is available in Manitoba; IVF is covered for bilateral tube blockage in Ontario; several other provinces have petitions to cover IVF under review.

^c 50% of three treatment cycles covered by statutory health insurance.

^d Available in a limited number of centres.

Table 3. Advantages and disadvantages of contraception options in HIV (Trussell, 2007).

Method	Advantages	Disadvantages^Footnotea
Condoms (male)	STI/HIV protection	Partner cooperation needed Requires correct technique Inconvenient/may interfere with sexual intercourse Pregnancy prevention = 85%
Condoms (female)	STI/HIV protection Can be controlled by the woman	Requires correct technique Inconvenient/may interfere with sexual intercourse Pregnancy prevention = 79% Price and availability
Oral contraceptive pill	Effective Less blood loss Can be controlled by the woman Pregnancy prevention = 92%	Drug-drug interactions Possibly increased viral shedding No STI/HIV protection
Patch, ring, injectable combination	Effective Less blood loss Can be controlled by the woman Pregnancy prevention=patch: 92%; ring: 92%	Drug-drug interactions? Lack of data Increased viral shedding? No STI/HIV protection
DMPA	Low maintenance Effective Can be controlled by the woman Pregnancy prevention = 97%	No STI/HIV protection Possibly increased risk of HIV acquisition
Copper intra-uterine device	Convenient Effective Can be controlled by the woman Pregnancy prevention = 99.2%	Blood loss Increased pelvic infection No STI/HIV protection
Levonorgestrel-releasing intra-uterine system (LNG-IUS)	Long lasting Convenient Can be controlled by the woman Pregnancy prevention = 99.8%	Blood loss No STI/HIV protection Minimal research available in HIV
Cervical barrier	Some STI protection Good contraceptive effectiveness if used correctly Can be controlled by the woman Pregnancy prevention = 84%	Increased urinary tract infections Requires correct technique No STI/HIV protection
Sterilisation	Low maintenance Effective Can be controlled by the woman Pregnancy prevention = 99.5%	Irreversible Expensive Invasive No STI/HIV protection

STI, sexually transmitted infection; HIV, human immunodeficiency virus.

^a Pregnancy prevention: The percentage of women who did not experience an unintended pregnancy during the first year of typical use of contraception in the USA.

Table 4. Drug interactions between hormonal contraception and various antiretroviral agents.^a

Antiretroviral agent	Effect on drug concentration	Recommended action
Protease inhibitors (PI)
Atazanavir (ATV)	↑ EE AUC 48% ↑ NE AUC 110%	OK for use OCP should contain ≤30mcg EE. Monitor for side effects, or use alternative method
Atazanavir/ritonavir (ATV/r)	↓ EE ↑ norgestimate (active metabolite of NG)	OK for use OCP should contain≥35mcg EE
Darunavir (DRV), Darunavir/ritonavir (DRV/r)	↓ EE AUC 44% ↓ NE AUC 14%	Do not use
Fosamprenavir (FPV)	With amprenavir: ↑ EE, ↑ NE ↓ amprenavir C^min 20%	Do not use
Fosamprenavir/ritonavir (FPV/r)	↓ EE AUC 37% ↓ NE AUC 34%	Do not use
Lopinavir/ritonavir (LPV/r)	↓ EE AUC 42% ↓ NE AUC 17%	Do not use
Nelfinavir (NFV)	↓ EE AUC 47% ↓ NE AUC 18%	Do not use
Saquinavir/ritonavir (SQV/r)	↓ EE SQV kinetics not affected by OCP	Do not use
Tipranavir/ritonavir (TPV/r)	↓ EE AUC 48% NE: no significant change	Do not use
Nonnucleoside reverse transcriptase inhibitors (NNRTI)
Efavirenz (EFV)	↓ NG AUC 64% ↓ LN AUC 83% EE: no effect	Do not use
Etravirine (ETR)	↑ EE AUC 22% NE: No significant change	OK for use
Nevirapine (NVP)	↓ EE AUC 20% ↓ NE AUC 19%	Do not use
Rilpivirine (RPV)	↑ EE AUC 14% NE: no significant change	OK for use
Integrase inhibitor
Raltegravir (RAL)	No significant interaction	OK for use
Elvitegravir (ELV)^b	↓ EE AUC 25%	OK for use OCP should contain≤30mcg EE. Await more data
CCR5 antagonist
Maraviroc (MRV)	No significant interaction	OK for use

AUC, area under the time concentration curve (drug exposure); C^min, minimum concentration; EE, ethinyl estradiol; LN, levonorgestrel; NE, norethindrone; NG, norgestimate; OCP, oral contraceptive pill.

^a Adapted from DHHS (2011a), DHHS (2011b), DHHS (2012).

^b When taken as a elvitegravir/cobicistat/FTC/tenofovir fixed dose ‘quad’ formulation (German, Wang, Warren, & Kearney, 2011).

Table 5. Available global and European countries’ breastfeeding guidelines

Guidelines	Country	Guidance on breastfeeding for mothers living with HIV
WHO (in collaboration with UNAIDS, UNFPA and UNICEF) (2010)	Global	Mothers with HIV should be counselled about the risks and benefits of infant feeding and provided with specific guidance regarding their situation Mothers who choose to breastfeed should be supported in their choice Mothers who choose not to breastfeed should be provided with guidance and support around formula feeding In low and middle income countries exclusive breastfeeding is recommended for the first six months of life
British HIV Association (BHIVA) and Children's HIV Association (CHIVA) (2010)	UK	In the UK, mothers with HIV are recommended to refrain from breastfeeding from birth regardless of maternal viral load and ART All mothers with HIV should be supported to formula feed their infant In rare circumstances where a mother who is effective on combination ART with a repeatedly undetectable viral load chooses to breastfeed then maternal ART should be carefully monitored and continued until one week after all breastfeeding has ceased. Breastfeeding should be ceased by 6 months
Royal College of Obstetricians and Gynaecologists (RCOG) (2010)	UK	All mothers with HIV should avoid breastfeeding Women should be given supportive advice about formula feeding
DAIG and Österreichische AIDS-Gesellschaft (2011b)	Germany	Mothers are advised not to breastfeed, according to WHO guidelines
Grupo de expertas y expertos del plan nacional sobre el sida y de gesida (2011)	Spain	All mothers with HIV should avoid breastfeeding Women should be given supportive advice about formula feeding Formula is provided free of charge through the Public Health System
Ministero della Salute (2011)	Italy	All mothers with HIV should avoid breastfeeding Formula is provided free of charge through the National Health System
Prise en charge médicale des personnes vivant avec le VIH, France (2010)	France	All mothers with HIV should avoid breastfeeding Mothers with HIV should be counselled about the risks of breastfeeding and be given supportive advice about formula feeding

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