HIV and contraception

A practical clinical guide to counselling on and managing contraception, pre-conception planning, and menopause for women living with HIV

BACKGROUND

Women represent one quarter of the population living with HIV in Canada and are an increasingly important sector of the HIV community. While some women's health issues such as cervical cancer screening and management are well addressed in HIV management guidelines, others are not. These include sexual and reproductive health factors such as contraception, pre-conception planning, and menopause. Existing literature has shown that while women living with HIV in Canada receive good HIV care based on HIV care cascade indicators, their women's health and sexual and reproductive health care needs are not being met.

METHODS

In this article, we present a clinical guide for clinicians providing care for women living with HIV on three key women's health topics that are under-discussed during HIV care visits: (1) contraception, (2) pre-conception planning, and (3) menopause.

RESULTS

We have summarized the most pertinent clinical factors on each topic to support straightforward counselling and present important considerations in the context of HIV-related diseases and treatment. Finally, when relevant, we have provided practical stepwise approaches for addressing each of these women's health care topics when seeing a patient during a visit.

CONCLUSIONS

It is important that HIV specialists stay well-versed in the complex clinical interactions between HIV treatment and management of women's health issues.

Long-Acting Anti-HIV Drugs Targeting HIV-1 Reverse Transcriptase and Integrase

One of the major factors contributing to HIV-1 drug resistance is suboptimal adherence to combination antiretroviral therapy (cART). Currently, recommended cART for HIV-1 treatment is a three-drug combination, whereas the pre-exposure prophylaxis (PrEP) regimens consist of one or two antivirals. Treatment regimens require adherence to a once or twice (in a subset of patients) daily dose. Long-acting formulations such as injections administered monthly could improve adherence and convenience, and thereby have potential to enhance the chances of expected outcomes, although long-lasting drug concentrations can also contribute to clinical issues like adverse events and development of drug resistance. Globally, two long-acting antivirals have been approved, and fifteen are in clinical trials. More than half of investigational long-acting antivirals target HIV-1 reverse transcriptase (HIV-1 RT) and/or integrase (HIV-1 IN). Here, we discuss the status and potential of long-acting inhibitors, including rilpivirine (RPV), dapivirine (DPV), and 4-ethynyl-2-fluoro-2-deoxyadenosine (EFdA; also known as MK-8591), which target RT, and cabotegravir (CAB), which targets IN. The outcomes of various clinical trials appear quite satisfactory, and the future of long-acting HIV-1 regimens appears bright.

Antiretroviral implants for treatment and prevention of HIV infection

PURPOSE OF REVIEW

Poor adherence to oral antiretroviral formulations remains the major barrier to the success of long-term treatment and prevention strategies. Although a number of approaches have been developed for long-acting parenteral delivery of antiretroviral drugs, subcutaneous implants are a particularly promising technology as they may be able to provide protective drugs concentrations for a year or longer following a single implant. This review addresses the current status of preclinical and clinical development of antiretroviral implants.

RECENT FINDINGS

Subcutaneous implants have been widely used for hormonal contraception and the treatment of hormonally driven malignancies for more than 3 decades. These implants are economical to manufacture and deliver, but require special procedures for insertion and removal. They are generally well tolerated and can remain in place for as long as 5 years. A small number of investigational implants are under development for the delivery of antiretroviral drugs. The most advanced of these, containing the investigational antiretroviral MK-8591 (4'-ethynyl-2-fluoro-2'-deoxyadenosine), a potent nucleoside analog reverse transcriptase translocation inhibitor that demonstrates particular promise for subcutaneous implantation, is closest to testing in human subjects. Investigational implants containing tenofovir alafenamide and nevirapine have also been developed and tested in animal models.

SUMMARY

Long-acting antiretroviral implants are a promising new technology, but are in very early stages of development. Potential advantages of these systems include more consistent and predictable drug release than intramuscular injections, and the fact that implants can be removed in the case of adverse events or the desire to stop treatment.

Changing Trends in Pregnancy and Childbirth among Women Living with Human Immunodeficiency Virus at a Tertiary Hospital in Korea: A 28-Year Experience

BACKGROUND

The reports about fertility desire and pregnancy outcome among women infected with human immunodeficiency virus (HIV) in Korea are scarce. This study aimed to determine the changing trend in pregnancy incidence among women infected with HIV in Korea.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of women infected with HIV visiting Pusan National University Hospital between January 1990 and October 2018.

RESULTS

A total of 149 women with HIV infection visited the study hospital. Among them, 33 pregnancies in 24 (16.1%) women were identified. There were 17 live births (51.5%) and 13 abortions (39.4%), whereas 3 women (9.1%) were transferred to another hospital or were lost to follow-up. The number of live birth rose from 0 in 1990-1998 to 17 in 1999-2018. The proportion of repeated pregnancies after HIV diagnosis also increased steeply, from 14.3% in 1999-2008 to 50% in 2009-2018. However, the number of abortions also increased over time. There were 8 induced abortions, 7 (87.5%) of them were diagnosed with HIV infection during pregnancy and 3 (37.5%) were unplanned pregnancies. Eighteen babies, including 1 twin case, were born from 17 births. There was no mother-to-child HIV transmission in our study.

CONCLUSION

The number of pregnancies among women with HIV infection and repeated pregnancies after HIV diagnosis has been increasing in Korea, probably due to the desire of HIV patients to have more children. However, the number of abortions also increased, probably due to health concerns and uncertain pregnancy outcome.

Long-Acting HIV Drugs for Treatment and Prevention

Antiretroviral drugs have revolutionized the treatment and prevention of HIV infection; however, adherence is critical for sustained efficacy. Current HIV treatment consists of three-drug regimens, and current HIV pre-exposure prophylaxis (PrEP) consists of a two-drug regimen; both generally require adherence to once-daily dosing. Long-acting formulations are useful in the treatment and prevention of other conditions (e.g., contraceptives, antipsychotics) and help promote adherence. Newer long-acting formulations of approved and investigational antiretroviral drugs in existing and newer mechanistic classes are under study for HIV treatment and prevention, including some phase III trials. Although long-acting antiretroviral drugs hold promise, some clinical challenges exist, including managing side effects, drug-drug interactions, pregnancy, and long-lasting drug concentrations that could lead to the development of drug resistance. This review aims to summarize currently available information on long-acting antiretroviral drugs for HIV treatment and prevention.