UK women with HIV need more conception and contraception advice

Women living with HIV in the UK would welcome greater provision of integrated sexual and reproductive healthcare services by their HIV clinics, according to three separate studies presented at the British HIV Association conference in Liverpool this week. There is a particular need for advice on conception and contraception that reflects the specific issues for women living with HIV.

Findings were presented on small studies of women attending HIV clinics in London (69 responses), Leicester (114 responses) and Birmingham (59 heterosexual men and women). Around two-thirds of both the Leicester and London samples were sexually active, which indicates a higher abstinence rate than in the general population.

The Leicester study focused on contraceptive use (at the time of the study, not provided by the HIV clinic). Almost all the sexually active women sometimes used contraception, and for 65% of women the method used was the male condom. Eighteen per cent of sexually active women doubled up condoms with other contraceptive methods, a strategy which can combine prevention of infections with use of more reliable contraceptives.

Less than 3% used contraceptive pills (much lower than in the general population), and 8% used implants, and both these methods are less effective if taken at the same time as antiretrovirals. Moreover, few women used condoms consistently. The authors suggest that more use could be made of long-acting reversible contraceptives – methods in this group that do not interact with antiretrovirals include injections (6% in this survey), intra-uterine devices (7%) and the intra-uterine system (4%).

The Birmingham study focused on their patients’ knowledge around conception and pregnancy, and identified high levels of need:

• 8% believed it was not possible for HIV-positive women to have HIV-negative children, and 13% thought that HIV-positive women couldn’t become pregnant without passing on HIV to their male partner.
• Only 22% were aware that with medical intervention, the risk of transmitting HIV to the baby was ‘very low’.
• 26% thought that HIV-positive men could directly transmit HIV to their baby.
• 47% thought that if a woman started antiretroviral therapy during pregnancy, the treatment would be lifelong.
• Only 42% knew that a caesarean section is not mandatory.
• Only 49% knew that breastfeeding is not recommended.

The researchers found that pre-conception advice would be welcomed, a finding echoed by the London study. Moreover, in London, 67% of respondents wanted to have sexual health screens in their HIV department, and 61% would prefer to have contraceptive advice from this source. Similarly, in Leicester, 79% of sexually active women said they would be interested in using a sexual and reproductive health clinic provided by the HIV department.

The researchers commented on various advantages of such services – principally, getting around the problem of disclosure of HIV status to a generic service, and the possibility of providing a holistic and integrated service. More specifically, the issue of interactions between hormonal contraceptives and antiretroviral treatment can be properly addressed, annual cervical screens can be provided, misconceptions about pregnancy and HIV can be addressed, and advice on safer sex and how to conceive without transmitting HIV can be provided.

Antenatal classes

Chris Wood of North Middlesex Hospital also presented a poster on the development of specific antental classes for women with HIV, the first programme of its type developed in the UK. Very few women at the hospital wanted to attend generic antenatal classes (which are recommended by NICE), which don't cover many issues of concern to women with HIV, such as disclosure and mode of delivery. Moreover, generic classes usually include strong promotion of breastfeeding and discourage taking medication during pregnancy, and so directly contradict the advice for women with HIV.

The hospital manages 30 to 45 pregnancies a year, and whilst pregnant women receive a great deal of individualised support, the focus on HIV-related issues has meant that some more basic points of antenatal preparation were sometimes neglected. The programme that has been developed also covers bottle feeding in some depth, including practical issues, health implications and problems of disclosure and stigma.