Day 7 Introduction and Digest (May 9, 2006)
Welcome to the seventh day of our online forum on “Client and Provider Perspectives on Integration of Family Planning Counseling and HIV/AIDS Services”. We continue our discussion of provider perspectives which began yesterday. We start with a posting from Dr. Gina Brown and follow that with three comments from forum participants in Ethiopia, Pakistan and Zimbabwe on Dr. Joachim Osur’s comments from yesterday.
Today we have a posting from Gina M. Brown, M.D. Dr. Brown is an obstetrical specialist at the New York City Department of Health and Mental Hygiene. Early in her career she trained and worked at Harlem Hospital Center. Her experience as an Obstetrician in the Harlem clinic for women with substance abuse issues formed the background for her career working with HIV positive women. She was first Medical Director for Cicatelli Associates Incorporated, a non-profit organization that provides training and technical assistance specifically in the areas of HIV and women’s health to health care providers who work with underserved communities. As an Assistant Professor of Clinical Obstetrics and Gynecology, at the College of Physicians and Surgeons, Columbia University, Dr. Brown was the Women’s Health Director of the Women and Children Care Center at Columbia, a clinic that provides comprehensive care for HIV positive women and their families. At the Center, she was a co-investigator for the Women and Infant’s Transmission Study (WITS) and the Pediatric AIDS Clinical Trials Group (PACTG). Dr. Brown was a member of the WITS Executive Committee and served as the Co-Chair of the Adult Working Group. She served as the Chair of the NIH Office of AIDS Research Advisory Council (OARAC) for 2004 and has co-chaired the Minority and Women and Girls working groups. She was a member of the New York City HIV Planning Council where she served as Chair of the Health Work Group. She also is a member of the Boards of Directors for Iris House and the Alliance for Women’s Equality.
Throughout the week, feel free to send questions or comments to Dr. Brown, as well as submit your own experiences, findings or lessons learned on the topic of the week. Please refer to the submission instructions and guidelines you received last week on how to post comments/questions for the online forum. Remember there are three ways to respond:
· simply click "reply" to this e-mail and post your comment,
· send your to fphivintegration@ibp.wa-research.ch
· log into the forum website at http://my.ibpinitiative.org/Community.aspx?c=d1f835b2-0c72-420a-9ade-88186b49abe7 with the username and password you received.
We look forward to rich and interesting discussions. Thanks for participating!
Best regards,
HCP and INFO Teams
Integrating Family Planning and HIV Care-The Provider’s Role
HIV and Family planning care appear to be disparate areas of health care, but are uniquely suited to integration. While many think of family planning as solely contraception, it also should include preconception counseling to allow women to plan a healthy pregnancy.
Current efforts to identify HIV positive women early in the course of pregnancy have led to the implementation of HIV testing in family planning and pregnancy testing sites. Women are offered HIV counseling and testing and receive their HIV rapid test results in the same setting in which they either learn about a pregnancy or are offered contraception care. For women who test HIV positive, counseling and education about HIV and its treatment comes along with pregnancy or contraception information. Women who are pregnant and HIV positive receive information about HIV antiretroviral therapy that can be used to reduce mother to child HIV transmission. Women already in HIV care who seek family planning services, also receive education about reducing mother to child HIV transmission.
HIV clinicians who care for women have the opportunity to positively impact pregnancy by working with women to decrease their viral load to undetectable levels, decrease the risk for Mother to child HIV transmission using appropriate antiretroviral therapy (ARVs), and optimize maternal health. Counseling about medication safety, vertical transmission, and long term treatment decisions is required to effectively ensure pregnancy safety and general health.
The integration of family planning and HIV care highlights the skills of both providers to counsel patients about health maintenance, and educate and correct misinformation. Primary prevention/ prevention for positives efforts by HIV clinicians require obtaining the same information as taking sexual health history by family planning clinicians. Information is obtained about sexual practices and sexual partners, and education about safe sex is exchanged. Current pregnancy status, plans for future pregnancy, and current use of contraception use can easily be added to the conversation.
Integration of HIV and family planning provides the opportunity to address the issues of medication interactions and safety. With increasing numbers of available antiretroviral therapies, information about medication safety during pregnancy, and newly studied interactions between ARVs and hormonal contraceptives, family planning providers and HIV providers have an opportunity and obligation to educate patients about these issues. Health providers who practice in either the family planning or HIV care setting and work with women have the unique opportunity to talk with HIV positive women before they become pregnant. This facilitates a discussion about optimizing health before pregnancy, choosing when to become pregnant and safely preventing pregnancy. It also facilitates discussion about choosing antiretroviral therapy that will be safe during pregnancy and allow for effective antiretroviral therapy and contraception use.
While HIV information for family planning providers and family planning information for HIV providers can appear to be quite complex, It can be distilled into a manageable discussion of available information. The US public Health Service (USPHS 2005) reports on the studies that have been conducted to date. The following antiretrovirals should be avoided in women who are pregnant, planning a pregnancy, or not actively using effective contraception:
Efavirenz (Sustiva) is known to cause neural tube defects
There is limited data on the safety of Tipranavir, Atazanavir, and Kaletra (Lopinavir/ritonavir) during pregnancy
Didanosine (ddI) and Stavudine (d4t) used in combination, have been associated with fatal cases of lactic acidosis during pregnancy
Nevirapine use in women with a CD4 count greater than 250 has been associated with liver dysfunction
Other studies have shown interactions between ARV and hormonal contraceptives:
Indinavir, Amprenavir (presumably also Fosamprenavir), Atazanvir, Delavirdine, and Sustiva all increase Estrogen and Progesterone levels.
Lopinavir, Nelfinavir, Nevirapine, and Kaletra (Lopinavir/Ritonavir) and Tipranavir/Ritonavir decrease estrogen levels.
Nelfinavir also decreases progesterone levels
Amprenavir is decreased by 20% when used with estrogen or progesterone.
What do both HIV providers and family planning providers need to know?
Hormonal contraception should not be used with patients who are using Amprenavir because blood levels of Amprenavir are decreased and this may result in Amprenavir resistance.
Alternative contraception other than or in addition to combined hormonal contraception should be considered in patients taking Nelfianvir, Ritonavir, Lopinavir, Nevirapine, Kaletra, and Tipranavir/Ritonavir, because the contraception may be less effective. This is a theoretical risk as there is currently no data regarding increased pregnancy risk.
Because of its teratogenicity, Efavirenz should be avoided in patients who are or could become pregnant.
Patients who are using Atazanavir should use the lowest effective dose of combined hormonal contraceptives because the increase in estrogen levels cause by Atazanavir may increase the risk for thromboembolic disease related to estrogen use.
The NIH web site www.aidsinfo.nih.gov should be routinely reviewed for pregnancy and contraceptive interactions. This website posts updates about HIV medication interactions.
When choosing or changing ARVs, HIV providers should inquire about a patient’s current pregnancy status, plans to become pregnant, and the type of contraception currently being used. Family planning providers should review the medications currently being taken by HIV positive clients when choosing contraception or diagnosing a new pregnancy. Either type of provider is equipped to recognize medication interactions or safety issues that may impact women. Active integration of family planning and HIV care will ensure the best outcomes for reproductive age HIV positive women.
Dr. Gina Brown
Comments and Questions from Forum Participants
-- Yonas Asfaw, Ethiopia
Dear Forum participants,
This is Yonas Asfaw from Ethiopia. I am really convinced with the option provided by Dr. Joachim Osur in integrating HIV/AIDS and Family Planning service. *The option of integrating HIV/AIDS with the existing family Planning service* will better work for the resource poor countries. Especially in the rural population, where there is better access for family planning service as compared with HIV/AIDS service. my worry is that HIV/AIDS is sensitive issue with the existing stigma and discrimination and poor access for service, treatment and qualified counsellor. I would be glad if I can get practical experience in integrating HIV/AIDS with the existing reproductive health service particularly in the rural population where there is poor access for health service.
Thanks - Yonas
-- Dr. Linda Stranix-Chibanda, Zimbabwe
I agree wholeheartedly with the sentiments of Dr Osur and thank him for expressing this so eloquently. I work in urban Zimbabwe in the PMTCT programme and it seems to be very similar to the setting described in the posting.
One way to address the staffing issue is to delegate certain duties to community volunteers, thus offloading the midwives who are left to concentrate on the clinical aspects of care. We have much experience with
this in Zimbabwe, where community volunteers have been trained to administer VCT for PMTCT at primary clinic level and provide basic couselling support to PLWHA. I would like to see this cadre trained in counselling for family planning as well. This would allow them to improve FP services to PLWHA. If such a cadre were stationed in FP units, they would be able to offer VCT for HIV in these settings, without increasing the burden on the nusing staff.
In the past, we had community health workers living and working in the villages who had been trained in FP counselling and who would move around on bicycles dispensing products to the clients' homes. Such an activity could be extended to provide counselling for HIV, but would not be able to offer testing.
Dr Lynda Stranix-Chibanda
Paediatrician
-- Nasreen Khan, Pakistan
Greetings from Pakistan
When we talk about “Client and Provider Perspectives on Integration of Family Planning Counseling and HIV/AIDS Services.”, we are talking of two different issues; issues related to supply of integration and issues related to demand for integration. Each perspective has different issues.
When we examine supply issues, Dr Osur has very well elaborated on time, technical skills of providers, lack of SDPs, Lack of staff and enough referral linkages etc. However, most important thing is maintenance of quality of care of such services and changing provider’s attitude. My question is how to address these two.
Talking of demand issues, the integration policy can not be generalized to all areas, I believe it should be geographic area specific or as per need. I need to know how to integrate services in different settings?
Regards
Nasreen Khan