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Ontario study calls for
pregnancy planning programs
for HIV-positive women

5 December 2011

The widespread availability of potent combination therapy for HIV, commonly called ART or HAART, has greatly improved the health of HIV-positive people. Furthermore, researchers estimate that many HIV-positive people who begin therapy today and who have minimal co-existing health complications and who are engaged in their care and treatment can have near-normal life spans. Faced with this possibility, some HIV-positive women (and men) are considering having families.

ART-together with preconception planning, prenatal care and interventions during and after birth-has resulted in a very low risk of HIV transmission from mother to child, particularly in high-income countries such as Canada. As a result, more HIV-positive women can have a safe and healthy pregnancy.

Unintended pregnancies are relatively common among HIV-negative people, with some surveys finding rates of 49% in the U.S. and 30% in the province of Ontario.

A team of researchers led by Dr. Mona Loufty has surveyed more than 400 HIV-positive women in Ontario about issues related to pregnancy. They found that the rate of unintended pregnancy was high-about 56%. This rate was similar to those found in surveys of HIV-positive women in Argentina (55%) but less than that found among some adolescent women in the U.S. (83%).

Dr. Loufty and colleagues call for pregnancy planning programs and encourage health care providers to include discussion about "pregnancy planning, healthy preconception lifestyle and contraception into routine HIV care, to support the health of women and their partners and protect future children by reducing [the risk of HIV transmission from mother to child]."

Study details

As part of a larger study, between October 2007 and April 2009 researchers recruited HIV-positive women between the ages of 18 and 52 from 38 clinics and AIDS service organizations across Ontario. All women had previously been pregnant. The average profile of the women surveyed was as follows:

  • age - 38 years
  • CD4+ count - 300 cells
  • 74% were currently taking ART
  • 16% were co-infected with hepatitis C virus
  • 60% were born outside of Canada
  • 51% were living in Toronto
  • 51% were receiving government financial assistance
  • nearly 80% earned less than $40,000 per year

Results-Unintended pregnancy

In total, 56% of the women disclosed that their last pregnancy was unplanned. This rate was significantly greater than has been reported for HIV-negative women living in Ontario (30%) and the U.S. (49%).

Taking many factors into account, the researchers found two that were significantly associated with unintended pregnancy in these women's lives:

  • never having been married
  • never having given birth

Factors such as age, ethnicity, religion and years living in Canada had no significant impact on unintended pregnancy.

Happiness

The Ontario survey also asked participants about their level of happiness with their last pregnancy. A total of 92% of women who had planned their last pregnancy answered that they were "happy or very happy" with their last pregnancy. However, among women whose last pregnancy was unplanned, 49% disclosed that they were "happy or very happy" with that pregnancy. This difference was statistically significant.

According to the study team, other analyses revealed that women who were happy with their last unplanned pregnancy were "more likely to be married or have a common-law partner and have given birth at least once."

The need to talk

According to the study team, the Ontario research shows that HIV-positive women need to be educated about "pregnancy planning, family planning and contraception." A first step in this direction would be a discussion by health care providers with their female patients.

Such discussions are important because one commonly used anti-HIV drug, efavirenz (Sustiva, Stocrin and in Atripla), can cause birth defects. Women who are taking this drug and who want to have a baby can be switched to different drug. Women who are not interested in becoming pregnant can be encouraged to use contraceptive measures.

Reducing unintended pregnancies could also help to reduce abortions among HIV-positive women. In the Ontario study, 47% of participants disclosed that they had an abortion.

Researchers found that 78% of women in the study gave birth to "at least one child" before they were diagnosed with HIV infection. In contrast, after they learnt about their HIV status, only 42% of the women gave birth. The reason for this difference is not certain-it may have been due to achieving the desired number of children, the relative age of the women or a consequence of having HIV and its associated stigma.

In addition to encouraging clinicians to initiate discussions about pregnancy planning and a "healthy preconception lifestyle," Dr. Loufty and colleagues are in the process of developing Canadian guidelines on pregnancy planning and fertility programs for HIV-positive women.

RESOURCES:

Birth rights

You can have a healthy pregnancy if you are HIV positive

Nutrition during and after pregnancy

-Sean R. Hosein

REFERENCES:

  1. King R, Khana K, Nakayiwa S, et al. "Pregnancy comes accidentally-like it did with me": reproductive decisions among women on ART and their partners in rural Uganda. BMC Public Health . 2011 Jul 5;11:530.
  2. Loutfy M, Raboud J, Wong J, et al. High prevalence of unintended pregnancies in HIV-positive women of reproductive age in Ontario, Canada: a retrospective study. HIV Medicine . 2011; in press.
  3. von Linstow ML, Rosenfeldt V, Lebech AM, et al. Prevention of mother-to-child transmission of HIV in Denmark, 1994-2008. HIV Medicine . 2010 Aug;11(7):448-56.

...positive attitudes are not simply 'moods'

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