Updated
Reviewed
Dec. 29, 2020

Preconception Counseling and Care for Women of Childbearing Age with HIV

Overview

Panel's Recommendations Regarding Preconception Counseling and Care for Women of Childbearing Age with HIV
Panel's Recommendations
  • Discuss reproductive desires with all women of childbearing age on an ongoing basis throughout the course of their care (AIII).
  • Provide information about effective and appropriate contraceptive methods to reduce the likelihood of unplanned pregnancy (AI).
  • During preconception counseling, provide information on safe sex and encourage the elimination of alcohol, tobacco, and other drugs of abuse. With the increasing prevalence of the opioid epidemic, if elimination is not feasible, clinicians should provide appropriate treatment (e.g., methadone or buprenorphine) or counsel patients on how to manage health risks (e.g., access to a syringe services program) (AII).
  • Women with HIV should attain maximum viral suppression before attempting conception for their own health to prevent sexual HIV transmission to partners without HIV (AI) and to minimize the risk of in utero HIV transmission to the infant (AI).
  • When selecting or evaluating an antiretroviral (ARV) regimen for women of childbearing age with HIV, consider a regimen’s effectiveness, a woman’s hepatitis B status, the teratogenic potential of the drugs in the ARV regimen, and the possible adverse outcomes for the mother and fetus (AII). See Teratogenicity and Recommendations for Use of Antiretroviral Drugs During Pregnancy for more information. The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission emphasizes the importance of counseling and shared decision making regarding all ARV regimens for people with HIV (AIII). 
  • HIV infection does not preclude the use of any contraceptive method; however, drug-drug interactions between hormonal contraceptives, antiretrovirals, and other medications should be considered (see Table 3). (AII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Overview

The Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and other national organizations recommend offering all women of childbearing age comprehensive family planning and the opportunity to receive preconception counseling and care as a component of routine primary medical care. The purpose of preconception care is to improve the health of each woman before conception by identifying risk factors for adverse maternal or fetal outcomes, tailoring education and counseling to patients’ individual needs, and treating or stabilizing medical conditions to optimize maternal and fetal outcomes.1 Preconception care is not something that occurs in a single clinical visit; rather, it requires integrating ongoing care and interventions into primary care to address the needs of women during the different stages of reproductive life. Integrating comprehensive family planning and preconception care into routine health care visits is important because almost half of all pregnancies in the United States are unplanned.2–5 Providers should initiate and document a nonjudgmental conversation with all women of reproductive age about their reproductive desires because women may be reluctant to bring up the subject themselves.6–10 Health care providers who routinely care for women of reproductive age with HIV play an important role in promoting preconception health and informed reproductive decisions. However, even among providers who offer primary care to women with HIV, the delivery of comprehensive reproductive counseling often falls short of the current guidelines.11–13

The fundamental principles of preconception counseling and care are outlined in the CDC Preconception Care Work Group’s Recommendations to Improve Preconception Health and Health Care. In addition to the general components of preconception counseling and care that are appropriate for all women of reproductive age, women with HIV have specific needs that should be addressed.14–17 Health care providers should—

  • Discuss reproductive options; actively assess women’s pregnancy intentions on an ongoing basis throughout the course of care; and, when appropriate, make referrals to the experts of HIV and women’s health, including experts in reproductive endocrinology and infertility when necessary.6,18
  • Recognize that the primary treatment goal for women who are on antiretroviral therapy (ART) and are planning a pregnancy should include sustained suppression of plasma viral load below the limit of detection before conception, which is important for the health of the woman because the risk of perinatal HIV transmission is minimized and sexual HIV transmission to a partner without HIV is prevented (see Reproductive Options for Couples When One or Both Partners Have HIV).
  • Explain to women that people with HIV who take ART as prescribed and who achieve and maintain an undetectable viral load have effectively no risk of transmitting HIV through sex, commonly known as Undetectable = Untransmittable or U=U. For more information, see Let’s Stop HIV Together from CDC.
  • Encourage sexual partners to receive HIV counseling and testing so that they can seek HIV care if they have HIV or seek advice about oral pre-exposure prophylaxis (PrEP) and other measures to prevent HIV acquisition if they do not have HIV.
  • Counsel women on eliminating the use of alcohol, tobacco, and other drugs of abuse. The use of opioids should be treated (e.g., with methadone or buprenorphine) and managed appropriately (e.g., provide access to syringe services program) when elimination is not feasible.
  • Counsel women on maintaining a healthy diet and healthy weight before and during pregnancy.
  • Counsel women who are contemplating pregnancy to take a daily multivitamin that contains 400 mcg of folic acid to help prevent neural tube defects (NTDs). Women with a history of having a child with  NTDs, a family history of NTDs, or on certain anti-epileptic medications are candidates for receiving a higher dose (1–4 mg) of folic acid.
  • Educate and counsel women about the risk factors for perinatal HIV transmission, the strategies to reduce those risks, and the potential effects of HIV or taking antiretroviral drugs (ARVs) during pregnancy on pregnancy course and outcomes. Education and counseling also should be directed at helping women to understand the recommendation that women with HIV in the United States not breastfeed because of the risk of transmission of HIV to their infants and the availability of safe and sustainable alternatives to infant feeding.
  • Support women’s shared decision making about ART and educating and counseling them about the factors that affect the selection of ARVs for women who are trying to conceive, pregnant women, or postpartum women. This support includes discussing the small but statistically significant increase in the risk of infant NTDs when dolutegravir (DTG) is taken around the time of conception with women who currently are receiving DTG as part of their ART regimen or with women who wish to be started on DTG. For more information, see Teratogenicity, updated guidance about the use of dolutegravir in pregnancy in Recommendations for Use of Antiretroviral Drugs During Pregnancy, Dolutegravir, and Appendix C:  Antiretroviral Counseling Guide for Health Care Providers: Pregnant Women and Women who are Trying to Conceive.
  • Consider the following factors when prescribing ART to women of childbearing age: the regimen’s effectiveness, an individual’s hepatitis B virus (HBV) status, the potential for teratogenicity, the likelihood of developing drug resistance, and the possible adverse outcomes for mother and fetus.19–21
  • Use the preconception period to modify the ARV regimen for women who are contemplating pregnancy to optimize virologic suppression and minimize potential adverse effects (see Recommendations for Use of Antiretroviral Drugs During Pregnancy and Table 5).
  • Recognize that women with perinatally acquired HIV may have special needs22 (see Prenatal Care, Antiretroviral Therapy, and HIV Management in Women with Perinatal HIV Infection).
  • Evaluate and manage therapy-associated adverse effects (e.g., hyperglycemia, anemia, hepatotoxicity) that may affect maternal-fetal health outcomes.
  • Administer all vaccines as indicated (see Guidance for Vaccine Recommendations for Pregnant and Breastfeeding Women and 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host), which includes vaccination for influenza, pneumococcus, HBV, and tetanus. All women, including those with HIV, should receive Tdap (tetanus, diphtheria, and pertussis) vaccination during pregnancy. 
  • Offer all women who currently do not desire pregnancy the effective and appropriate contraceptive methods to reduce the likelihood of an unintended pregnancy. Women with HIV can use all available contraceptive methods, including hormonal contraception (e.g., pill, patch, ring, injection, implant) and intrauterine devices (IUDs).23 Providers should be aware of potential interactions between ARV drugs, hormonal contraceptives, and other medications that could lower contraceptive efficacy or increase the risk of such adverse effects as blood clots (see Table 3 below).
  • Offer emergency contraception as appropriate, including emergency contraceptive pills and the copper IUD (see the ACOG Practice Bulletin on emergency contraception). Emergency contraceptive pills that contain estrogen and progestin and those that only contain levonorgestrel (LNG) may have interactions with ARV drugs that are similar to the ones observed with combined oral contraceptives.24 No data are available on potential interactions between ARV drugs and ulipristal acetate, a progesterone receptor modulator; however, ulipristal acetate is metabolized predominantly by cytochrome P450 (CYP) 3A4, so interactions may occur (see the HIV Drug Interaction Checker).
  • Optimize the woman’s health prior to conception (e.g., ensure appropriate folate intake, test for all sexually transmitted infections and treat as indicated, consider the teratogenic potential of all prescribed medications, and consider switching to safer medications).

Drug-Drug Interactions Between Hormonal Contraceptives and Antiretroviral Therapy

Data on drug interactions between ARVs and hormonal contraceptives primarily come from drug labels and several studies on the pharmacokinetics (PKs) and pharmacodynamics among the different forms of contraception and ARVs.24–45 The contraceptive effectiveness of the levonorgestrel IUD is largely through local (i.e., intrauterine) release of levonorgestrel, not through systemic absorption. CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use lists the levonorgestrel IUD as category 1 (no restrictions) in drug interactions with all ARVs in women who already have an IUD and category 1/2 (benefits outweigh risk) for those initiating the use of an IUD.

Hormonal contraceptives can be used with ARVs in women without other contraindications. Additional or alternative methods of contraception may be recommended when drug interactions are known. For women who are using ritonavir (RTV)-boosted protease inhibitors (PIs) and who are also on combination hormonal contraceptives (e.g., pills, patches, rings) or progestin-only pills, the use of an alternative or additional method of contraception may be considered because the area under the curve (AUC) of hormones may be decreased with the use of some RTV-boosted PIs (i.e., darunavir/ritonavir [DRV/r], fosamprenavir/ritonavir, and lopinavir/ritonavir [LPV/r]) but not others (see Table 3). Depot medroxyprogesterone acetate (DMPA) can be used without restriction because of its relatively higher dose than other progesterone-based contraception, and limited studies have shown no significant interaction between DMPA and ARVs.26,28,38,46 Doses of hormonal contraceptives do not need to be adjusted in patients who are receiving nucleoside reverse transcriptase inhibitors.

Although contraceptive implants (e.g., etonogestrel [ENG]/LNG) generally can be used in women who are receiving ARVs, both PK and clinical data suggest that these implants have decreased efficacy when used with efavirenz (EFV)-based regimens.36,47–49 Scarsi et al. reported on three groups of Ugandan women with HIV: those who were not on ART (17 women), those taking nevirapine (NVP)-based ART (20 women), and those taking EFV-based ART (20 women) who had LNG implants placed and had LNG PK levels assessed at 1, 4, 12, 24, 36, and 48 weeks post-insertion. The geometric mean ratios of LNG concentrations (patients taking EFV-based ART vs. ART-naive patients) were 0.53 at 24 weeks and 0.43 at 48 weeks. Three pregnancies occurred in the EFV group (15%) between weeks 36 and 48, whereas no pregnancies occurred in the ART-naive or NVP groups.40

In a study of 570 women with HIV in Swaziland who had LNG implants (i.e., Jadelle), none of the women on NVP- or LPV/r-based regimens (n = 208 and n = 13, respectively) became pregnant, whereas 15 women on EFV (n = 121; 12.4%) became pregnant.36 Because of their overall efficacy, implants remain as effective as or more effective than oral and injectable contraceptives among women with HIV who are using EFV, and all hormonal contraceptives remain more effective than no contraception among these women.48,50 A study collected data from 5,153 women with HIV who were followed prospectively for 1 to 3 years. During the follow-up period, 9 percent of the women used implants (mostly LNG), 40 percent used injectables, and 14 percent used oral contraceptives; 31 percent of these women took ART during the follow-up period, mostly NVP-containing (75%) or EFV-containing (15%) regimens. Among women who were not using contraception, pregnancy rates were 13.2 per 100 person-years for those who were on ART and 22.5 per 100 person-years for those who were not on ART. Implants greatly reduced the incidence of pregnancy among women on ART (adjusted hazard ratio [aHR] 0.06; 95% confidence interval [CI], 0.01–0.45) and women who were not on ART (aHR 0.05; 95% CI, 0.02–0.11). Injectables and oral contraceptives also reduced pregnancy risk but to lesser degrees. ART use did not significantly diminish contraceptive effectiveness, although all methods showed nonstatistically significant reduced contraceptive effectiveness when a woman used EFV concurrently.50

In a retrospective study among 1,152 women with HIV and using either EFV or NVP and ENG or LNG implants, there were 115 pregnancies, yielding a pregnancy incidence rate of 6.32 (5.27–7.59), with a rate of 9.26 among ENG and 4.74 among LNG implant users, respectively. Pregnancy incidence rates did not differ between EFV- and NVP-based regimens (incidence rate ratio [IRR] = 1.00; 95% CI, 0.71–1.43). No pregnancies were recorded among women on PI-based regimens. Pregnancy rates of EFV- and NVP-containing regimens were similar at 6.41 (4.70–8.73) and 6.44 (5.13–8.07), respectively. Pregnancy rates differed by implant type with LNG implant users half as likely to become pregnant as ENG implant users (IRR = 0.51; 95% CI, 0.33–0.73, P > 0.01).51

Genetic contributions also may influence observed drug-drug interactions between contraceptives and ARVs. In a study of 19 women not on ART (control group), 19 women on EFV, and 19 women on NVP with ENG implants, the women in the EFV group with cytochrome P450 2B6 (CYP2B6) 516 G>T were associated with 43% lower ENG Cmin and 34 percent lower AUC0–24 at 24weeks. For patients on NVP, NR1I2 63396 C>T  had  lower ENG Cmin and 37 percent lower AUC0–24 at 24weeks.44

Other medications, such as those for tuberculosis (TB) treatment and ARVs, also may have drug-drug interactions with contraceptives.  A pharmacokinetic study of DMPA among women with HIV/TB coinfection who received EFV-based treatment and rifampicin-based TB treatment showed that among 42 evaluable women, five women (11.9%; 95% CI, 4.0–25.6%) had medroxyprogesterone acetate (MPA) <0.1 ng/ml at week 12, the level above which ovulation is prevented; of these women, one had MPA <0.1 ng/ml at week 10. The median clearance of MPA was higher in women on EFV compared with women with HIV who were not on ART, thus leading to subtherapeutic concentrations of MPA in 12 percent of women at week 12.52 The authors suggest redosing DMPA more frequently, such as every 8–10 weeks.

Because data are limited on pregnancy rates among women on different hormonal contraceptives and ARVs, some of the dosing recommendations in Table 3 are based on consensus expert opinion. Whenever possible, the recommendations are based on available data regarding PK interactions between ARVs and combined hormonal methods, DMPA, and LNG and ENG implants. The smallest decrease in PK for which an alternative method was recommended was a 14 percent decrease in norethindrone (with DRV/r). For women who are using atazanavir without RTV boosting (ethinyl estradiol increase, 48%; norethindrone increase, 110%), the Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission (the Panel) recommends the use of oral contraceptives that contain ≤30 µg ethinyl estradiol. The Panel does not recommend any change in ethinyl estradiol dose in women who are receiving etravirine (ethinyl estradiol increased 22%), rilpivirine (ethinyl estradiol increased 14%), or indinavir (ethinyl estradiol increased 25%, norethindrone increased 26%).

A contraceptive vaginal ring containing segesterone/ethinyl estradiol (Annovera) has been approved by the U.S. Food and Drug Administration. No available drug-drug interaction studies with this new contraceptive vaginal ring and ARV and CYP inducers/inhibitors are known. The contraceptive possibly could be metabolized in the same way as ENG and ethinyl estradiol in the NuvaRing. Our recommendation is extrapolated from what is known with the NuvaRing. 

Table 3. Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives

Note: All recommendations in this table are based on consensus expert opinion. More details can be found in the CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.

Table 3. Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives
   
   
   
   
 

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Preconception Counseling and Care for Women of Childbearing Age with HIV

Overview

Panel's Recommendations Regarding Preconception Counseling and Care for Women of Childbearing Age with HIV
Panel's Recommendations
  • Discuss reproductive desires with all women of childbearing age on an ongoing basis throughout the course of their care (AIII).
  • Provide information about effective and appropriate contraceptive methods to reduce the likelihood of unplanned pregnancy (AI).
  • During preconception counseling, provide information on safe sex and encourage the elimination of alcohol, tobacco, and other drugs of abuse. With the increasing prevalence of the opioid epidemic, if elimination is not feasible, clinicians should provide appropriate treatment (e.g., methadone or buprenorphine) or counsel patients on how to manage health risks (e.g., access to a syringe services program) (AII).
  • Women with HIV should attain maximum viral suppression before attempting conception for their own health to prevent sexual HIV transmission to partners without HIV (AI) and to minimize the risk of in utero HIV transmission to the infant (AI).
  • When selecting or evaluating an antiretroviral (ARV) regimen for women of childbearing age with HIV, consider a regimen’s effectiveness, a woman’s hepatitis B status, the teratogenic potential of the drugs in the ARV regimen, and the possible adverse outcomes for the mother and fetus (AII). See Teratogenicity and Recommendations for Use of Antiretroviral Drugs During Pregnancy for more information. The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission emphasizes the importance of counseling and shared decision making regarding all ARV regimens for people with HIV (AIII). 
  • HIV infection does not preclude the use of any contraceptive method; however, drug-drug interactions between hormonal contraceptives, antiretrovirals, and other medications should be considered (see Table 3). (AII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Drug-Drug Interactions Between Hormonal Contraceptives and Antiretroviral Therapy

Table 3. Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives

Note: All recommendations in this table are based on consensus expert opinion. More details can be found in the CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.

Table 3. Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives
   
   
   
   

 

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