20th International AIDS Conference - Melbourne, Australia


THSA14 Women and ARV-based HIV Prevention: Challenges and Opportunities
  Non-Commercial Satellite
Venue: Room 111-112
Time: 24.07.2014, 18:30 - 20:30
Chair: Kathleen MacQueen, United States

Organizer: FHI 360
The challenges and opportunities experienced by women using ARV-based prevention technologies, such as oral PrEP and microbicide gels, will be examined by an expert panel organized by FHI 360, with support from USAID. An overview of current and future biomedical options for women will be presented, followed by dialogue on gender-relevant topics such as product adherence, fertility concerns, engagement of male partners in women’s microbicide use, adolescents’ use, how to communicate effectively with women about microbicides, and considerations for rolling out microbicide services for women within national health care systems. Panel members will engage in a series of questions to elicit cross-cutting discussion about the role of biomedical technology for women’s prevention needs. Substantial time will be provided for dialogue with the audience.
18:30
Refreshments and canapes served 18:00-18:40 approximately

18:40
Welcome
M. Stalker, United States

18:45
Introduction of Panelists
K. MacQueen, United States

18:55

Powerpoint
Overview of Current and Future ARV-based Prevention Options for Women
T. Mastro, United States

19:05
Panel and Audience Discussion
L. Pascoe, South Africa
J. Auerbach, United States
E. Bukusi, Kenya
K. Agot, Kenya
A. Corneli, United States
M. Stalker, United States
T. Mastro, United States

Powerpoints presentations
Overview of Current and Future ARV-based Prevention Options for Women - Timothy Mastro



Rapporteur report

Track C report by Elizabeth Bukusi


THAC0501 Women living with HIV are still missing highly effective contraception. Results from the ANRS-Vespa2 Study, 2011, France

Annabel Desgrées du Lou

Described the patterns of women living with HIV in France in 2007.   56% were women from African countries and migrant.

African women were younger than other women, more likely to have children and had partners ( similar) and had HIV for about 6 years.

Contraception : did not different between women from SSA and others . One in 5 did not use any or used traditional. Only 20% used highly effective methods. No difference between use of highly effective between SSA women and others.  No statistically significant difference on use when comparing health insurance, visit to gynecologist  in the last 12 months, or any cardiovascular risk.

One in 4 women not using any modern method among HIV positive women.  Among migrants, women with children are more likely to be using contraception .  Employment highly correlated

Among French and other migrant women, causal partners associated with low sexual activity and less likely to  use contraception. 

The study had the whole of France but did not ask about unwanted pregnancy.

Condom  is the most used method for HIV positive women.  Dual protection not widely promoted.

Conclusion : dual use not  promoted  . No difference  in contraception access for migrant and non migrant / French women.

Question : Did you look at the relationship between Highly effective contraception and the viral load.

Answer: This will need to be verified with the first author

Question : Are you planning to do any work with the care provider  since the physicians attitudes may be the one’s driving the lack of contraception options or may only promote condoms. Will you do any work with the providers.

Answer : informal discussions held  with the practitioners.  The providers seem to think that if one is HIV positive they must use condoms so they will need discussions to make them think of other contraception options that they can offer the women.

Question : Was there a difference among the French and the immigrants, was there  difference in the uptake of implants and IUCD ?

Answer: the French contraception of highest choice is the pill. The others are not as widely used so analysis not broken down into the other contraceptives and for the pill there was no difference.

Question : WHO office India ; What was the uptake in terms of post partum IUCD compared to the OCP.

This is cross sectional so no data on post partum available as the questions were asked about previous pregnancies.

Question : Malawi . What guidelines and policies would you provide in order to promote the use of a range of contraception.

Answer : yes,  this is the first analysis and the idea is to come back to the practitioners to improve the better use of and access of contraception for HIV positive women- and guidelines would be provided an policies put in place.

 

THAC0502 Condoms for contraception: patterns of contraceptive use among female sex workers in eThekwini District, KwaZulu-Natal, South Africa

 Jennifer Smit

 Patterns of contraceptive use among female sex workers in KZN. Women in RSA have challenges with RH problems. High HIV and STI. High pregnancy rates. Sex workers  at higher risk. Compare baseline at KZN at E-thekwiny .

The study is called DIFFER – multi country study including Kenya and India and Mozambique .  Started in 2011 to 2016. Focus is on baseline data .

Aim to improve services for RH among women.  Implementing a diagonal service for women.

For FSW  - respondent driven sampling-  RDS for recruitment and general women from the region from clinics.  Looked at network size to determine if appropriate .

FSW had lower education and had no current stable visiting partner and  80% of the clinic  women had a regular partner. In the last 5 years, 40% had an unplanned pregnancy among the FSW . Women from the clinics - most had not planned the last pregnancy. Contraception use FSW 88% and 35% among general women.

Primary contraception was condom  with use high among the FSW compared to the General population where over half use modern methods.  The injection was the most popular for the general population of women.  There is  a move to re train and reintroduce the IUCD. Condom use higher among the FSW  but not 100%.

HIV Status , self reported was similar,  in the two group sunder 50% and when measured among the FSW it was 67% ( still under 50% for general population0.  FSW get condoms from the Govt clinic.  They rely on condoms for contraception and do not use it 100 %. As per the current progressive Strategic plan for RH, dual methods to be promoted and multipurpose prevention technology -MPT will be good for this population.

Qs : Comment : IUCD were not recommended for women with high risk for STI and HIV is this still the case.

The WHO recommendation will be presented shortly. RSA uses the WHO guidelines.

Question :  age group 18-45 whey not younger or why not adolescents.

Answer : only 18 and older as guidelines only allow those over 18 and doing research under 18 requires parental consent. But it is right that this population s vulnerable and requites focused attention.

 

THAC0503 Hormonal contraception and HIV infection: results from a large individual participant data meta-analysis

Charles Morrison : FHI360.

Meta analysis of HIV and contraception :

Background : benefits of contraception are well accepted

From observational studies ; Determine if different contraceptives including hormonal contraceptives increase the risk of HIV acquisition.

Only included those using HV and HIV prospectively and at multiple end points,   women 14-49 and detect at least 15 sero conversion.  18 studies included in the final data set.  A total of 37,000 women .

HR -No association for OC, 1.6 for Depo and 1.5 for net N.

Adjusted for age, condom use

DMPA and COC 1.43

DMPA and Net en 1.32

Net En and CC  1.1?  

Effect modification by the region of the study.

Limitations of the differences in design and selection biases and residual confounding

Conclusion :Use of DMPA but not COC or Net En associated in increased risk of HIV acquisition .

The importance of  a well planned RCT  would be important

More contraception options which are safe are needed for women at risk for HIV

Question : Would this be adequate evidence for change in recommendations ? No, more stringent evidence needed

Question  South African : How fare are the discussion on when an RCT can be done to sort out this issue ? How far is the discussion to date?

Answer : ECHO trial in discussion, have site selection. Funding is being worked on to allow this to proceed.  

THAC0504 Weighing 17 years of evidence: does hormonal contraception increase HIV acquisition risk among Zambian women in discordant couples

Kristen Wal 

17 years of evidence does hormonal contraception increase the risk for HIV acquisition

HC used in areas where HIV prevalence is high eg Zambia where it is 14%.

WHO recommended HC at category 1 and advised condom use

Male positive and female negative serodiscordant couples.  Followed up for 3 months intervals and contraception provided.

Hormonal methods, Implant ( Norplant and Jadelle ) inaction DMPA nd COC

Interest on time to conversion – linked or unlinked infections to the partners.

Of 1393 , 18 % seroconverted and most infections were linked.  Most women not using a method or condoms.

The sero incidence  for OCPs was marginally statistically significant but for implants and injections not significant

In the Multivariate model there was no increase risk controlling for age, genital ulceration, inflammation , semen present in wet prep smear.

Even when analyzed by genetically linked infections, no increased risk observed.

Conclusion :No association after controls.  More counseling  needed for OC use, and during pregnancy

 

Question: Why did the men not get on treatment and do know the viral load  and how this affected the analysis

Answer : Men did initiate treatment and censored once on treatment.

Qs was there a comparison of women who did not use any contraception since they were grouped with condom use group?

Answer: yes this was taken care of in the sensitivity analysis

Qs : from Boston hospital. How was inflammation measured and was there a difference within the group.

Answer: Inflammation was self report, and on examination and also for any infections detected BV, Chlamydia and Candida. No difference noted.

 

THAC0505LB HIV and contraception - complex issues for safe choice: the latest recommendations from the World Health Organization (WHO

Marylyne Gaffield. WHO

MEC – medical Eligibily criteria for the last 20 years.   Evidence based for guidelines for contraceptive use for women  and men.

This includes women at risk , those living with HIV and those who are on HAART.  This is issued ahead of the guidelines which will be done by March 2015.

There are 4 categories

1.       Category or conditions  for which no restrictions

2.       Can be used but careful follow up

3.       Require careful clinical judgment and access to treatment

4.       Unacceptable risk and should not be used.

This can be made whether it is an imitation or continuing the method.

Where information is limited then it is limited to whether it can be used ( 1 or 2) or not ( 3,4)

WHO requirements using the PICO system has been used ( population intervention comparison outcome) .

Does the use of HC increase the risk for acquisition ? does it accelerate the disease progression

Does it increase the female to male transition ? Are there any interaction of HC and ARV ?

Grate evidence provided for  quality fo each evidence provided.

Recommendations :

HC : 1, all those listed, no restriction for women at high risk of HIV .   But for DMPA and Net N women at high risk may or may not increase the risk of HIV acquisition and they should be informed.,

For disease progression :  no change in recommendations

For female to male transmission of HIV ;  No change, low quality evidence

Does it affect ART :  no changes in the  recommendation , low quality of the studies 2 cohorts

Replaced terminology use   HIV infected mild  ( Stage  1 or 2 )  or HIV infected moderate or severe( Stage 3or 4)

Different recommendation for levonogesterone for imitation for IUCD, can initiate state 1 or 2, but for severe disease 3 or 4, do not start until condition improves but if had it can continue to use.

Evidence for contraceptive effectiveness and for effectives of the ART. Very little data available. This is available on the WHO.  Offer for NNRTI, NRTI And for integrase and Protease inhibitors.  Now offer specific recommendation on the drugs in specific. For Efavienz  and Nevirapine no restrictions for stage 1 and 2.

Clarification provided depending on the stage of the HIV disease for specific drugs.

 

 Conclusion :  Some changes in recommendations for specific issues for ART, terminology. No change in recommendations fro HC use . Clarification on dual use for those at risk maintained.




   

    The organizers reserve the right to amend the programme.