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No. 354-Canadian HIV Pregnancy Planning Guidelines

      Abstract

      Objective

      The objective of the Canadian HIV Pregnancy Planning Guidelines is to provide clinical information and recommendations for health care providers to assist Canadians affected by HIV with their fertility, preconception, and pregnancy planning decisions. These guidelines are evidence- and community-based and flexible and take into account diverse and intersecting local/population needs based on the social determinants of health.

      Intended Outcomes

      • Reduction of risk of perinatal HIV transmission (from mother to child) and horizontal HIV transmission (between partners/parents) by increasing the extent of pregnancy planning by individuals with HIV through informed discussions of safer options for conception.
      • Improvement of pregnancy and infant outcomes in the context of HIV through the provision of recommendations for healthy pregnancies.
      • Reduction of the stigma associated with pregnancy and HIV through education.
      • Increased access to pregnancy planning and fertility services for individuals affected by HIV through education.

      Evidence

      Literature searches were conducted by a librarian using the Medline, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase databases for published articles in English and French related to HIV and pregnancy and HIV and pregnancy planning for each section of the guidelines. The full search strategy is available upon request.

      Values

      The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care and through use of the Appraisal of Guidelines Research and Evaluation instrument for the development of clinical guidelines.

      Benefits, Harms, and Costs

      Guideline implementation should assist the practitioner in developing an evidence-based approach for the prevention of unplanned pregnancy, preconception, fertility, and pregnancy planning counselling in the context of HIV infection.

      Validation

      These guidelines have been reviewed and approved by the Infectious Disease Committee and the Executive and Council of the SOGC.

      Sponsor

      Canadian Institutes of Health Research Grant Planning and Dissemination grant (Funding Reference # 137186), which funded a Development Team meeting in 2016.

      Recommendations

      • 1.
        Reproductive health counselling, including contraception and pregnancy planning, should be offered to all people with HIV of reproductive age soon after HIV diagnosis and on an ongoing basis (II-3A).
      • 2.
        Counselling should be provided to all people with HIV of reproductive age on strategies to reduce horizontal and perinatal HIV transmission risk (I-A).
      • 3.
        Individuals should be counselled on all relevant aspects of pregnancy planning—such as maintaining a healthy diet and lifestyle; the cessation or reduction of smoking, drinking alcohol, and drug use; the risk of genetic disease occurrence, and prenatal screening—as outlined in current Canadian practice guidelines irrespective of their known HIV status (III-A).
      • 4.
        Folic acid (found in the form of vitamin supplements) should be initiated 3 months prior to becoming pregnant and for at least the first 3 months of pregnancy (II-3A).
      • 5.
        Prospective parents should be tested for sexually transmitted and other infections/comorbidities, even if they have conceived in the past and have no symptoms of infection (III-A).
      • 6.
        Counselling should include a discussion of the potential risk for both horizontal and perinatal HIV transmission, including perinatal transmission via breastfeeding and how transmission (or risk of transmission) might affect the mental health of 1 or both parents and other family members (III-A).
      • 7.
        Counselling should be performed by a knowledgeable provider in a supportive, nonjudgemental manner that takes into account factors specific to sexual diversity and ethnocultural and/or religious beliefs and practices (III-A).
      • 8.
        People with HIV who intend to conceive should be aware of the potential stigma and discrimination they may face from people who are less informed about the risks of perinatal and horizontal HIV transmission. They may therefore require further counselling to cope with psychosocial issues during the pregnancy or postpartum period (II-3A).
      • 9.
        The preconception period can be an important opportunity to achieve mental health stability. Assembling a care team that is appropriate to the individual's or couple's needs in the perinatal period has important implications for maternal and infant health outcomes (III-A).
      • 10.
        The intersection of HIV and substance use necessitates a supportive, non-stigmatizing discussion of substance use in the preconception period with referral to appropriate services, including harm reduction strategies, for both mother and infant (III-A).
      • 11.
        All people with HIV should be counselled on the possible ethical and legal aspects of pregnancy planning (III-A).
      • 12.
        People and couples affected by HIV who are considering pregnancy should be counselled on the possibility of legal sanctions if they do not permit antiretroviral therapy to be given to their baby after birth (III-B).
      • 13.
        People with HIV should be made aware of the possibility of criminal sanctions related to HIV non-disclosure and horizontal and/or perinatal transmission (III-C).
      • 14.
        Ethical considerations, including those related to the health status of a person with HIV or couples, should be discussed during preconception counselling, if relevant (III-B).
      • 15.
        Clinicians should review all medications that an individual with HIV may be using, including antidepressants, hepatitis treatment, pain medications, over-the-counter medications, and herbal and alternative medications, to ensure that they are safe during conception and pregnancy. Any changes to medications should be made prior to pregnancy (II-3A).
      • 16.
        All people with HIV who are planning to conceive should already be taking or imminently started on combination antiretroviral therapy, both for their own health and to prevent horizontal HIV transmission during the preconception period. They should be counselled on maintaining a high level of antiretroviral drug adherence to maintain a suppressed viral load (I-A).
      • 17.
        For women not on antiretroviral therapy, initiating combination antiretroviral therapy is recommended in the preconception period to achieve a suppressed viral load and management of drug-related side effects prior to conception (II-A).
      • 18.
        Women should avoid any drugs that are potentially teratogenic or considered toxic in the preconception period and in pregnancy. The safest, most efficacious antiretroviral regimen tailored to pregnancy should be selected (II-3A).
      • 19.
        Condomless sex or sperm washing should be avoided as the conception method until the partner with HIV has been on combination antiretroviral therapy for at least 3 months with at least 2 viral load measurements below the level of detection at least 1 month apart. Preferably the partner with HIV should have been on combination antiretroviral therapy with a suppressed viral load for 6 months. When rapid viral suppression is achieved through the use of new antiretroviral agents, 2 undetectable viral load measurements at least 1 month apart should still be achieved before initiating condomless sex or sperm washing (II-A).
      • 20.
        The data on pre-exposure prophylaxis should be discussed with all patients during preconception. HIV pre-exposure prophylaxis is not routinely recommended in the context of HIV and preconception. In the situation in which adherence and viral suppression in the infected partner cannot be confirmed, but conception attempts are still intended by the serodiscordant couple, pre-exposure prophylaxis should be recommended to the HIV-negative partner (II-A).
      • 21.
        In patients with hepatitis C co-infection, new highly effective direct-acting agents are commonly being used to cure hepatitis C. There is inadequate evidence regarding the potential effects of these agents in pregnant women, and they should be avoided in the immediate preconception period and during pregnancy. It is ideal to treat and cure a woman's hepatitis C prior to attempting conception. There is no evidence that newer agents affect the sperm and therefore can be used in the preconception period for men. However, ribavirin, an older drug that is still used, should not be used in individuals (i.e., women and men) for at least 6 months prior to conception (II-A).
      • 22.
        All recommendations with respect to combination antiretroviral therapy during the preconception period and during pregnancy should consider both the health of the person with HIV and prevention of both horizontal and perinatal transmission of HIV. Decisions regarding combination antiretroviral therapy should be made in consultation with an HIV specialist (III-A).
      • 23.
        Couples and individuals should be counselled thoroughly about all horizontal HIV transmission risk reduction methods before attempting conception and supported to make an informed choice about which of the many options for conception method is most appropriate and acceptable to them (III-C).
      • 24.
        Prospective parents should be informed about the rate of success, availability, and cost of each conception option (III-C).
      • 25.
        Couples and individuals who have attempted conception using a home-based method (e.g., condomless sex or home insemination) for 6 to 12 months without success should be referred to a gynaecologist or fertility specialist for a complete fertility workup and appropriate treatment (III-A).
      • 26.
        Pre-pregnancy counselling should include a discussion about all parenting options, including adoption, for all individuals and couples (III-C).
      • 27.
        If an individual or couple has attempted a recommended conception method for 6 to 12 months without success, assisted reproductive technologies, including intrauterine insemination or in vitro fertilization with or without intra-cytoplasmic sperm injection, with washed partner/parent sperm or a sperm donor should be recommended (II-3A).
      • 28.
        The Canadian HIV Pregnancy Planning Guidelines Development Team recommends that single women with HIV or women with HIV in a same-sex relationship be referred to a fertility specialist and counselled on the option of intrauterine insemination with donor sperm (III-C).
      • 29.
        For serodiscordant couples in which the man is living with HIV and is on combination antiretroviral therapy with virologic suppression, the Canadian HIV Pregnancy Planning Guidelines Development Team recommends attempting timed condomless sex for 6 to 12 months (I-A) or referral to a fertility specialist for consideration of sperm washing or use of donor sperm with intra-uterine insemination (II-2A) as the preferred initial methods of conception.
      • 30.
        Single men with HIV or a man with HIV in a same-sex relationship who has an HIV-negative or HIV-positive surrogate should be referred to a fertility specialist (III-A).
      • 31.
        The Canadian HIV Pregnancy Planning Guidelines Development Team recommends timed condomless sex for seroconcordant couples taking combination antiretroviral therapy with virologic suppression (II-3A).
      • 32.
        Seroconcordant couples should be counselled on the risks and benefits of timed condomless sex (including HIV super-infection and transmission of drug-resistant strains of HIV) (II-3A).
      • 33.
        People with HIV should be counselled about fertility issues that also occur in the general population, including genetic disorders and advanced maternal age, and offered infertility investigations and treatment if required (III-A).
      • 34.
        Fertility laboratories should follow Canadian Standards Association guidelines for infection control when handling HIV-positive materials and use additional procedures available for the processing of HIV-positive sperm to ensure the preparation of a virus-free sample (III-A).
      • 35.
        Potentially infectious samples should be processed in a separate laboratory or dedicated area with separate equipment within the main laboratory to reduce the risk of HIV contamination (III-A).
      • 36.
        Potentially infectious gametes and embryos should be stored in biocontainment straws and dedicated cryopreservation containers to minimize the risk of cross-contamination of samples (III-A).

      Key Words

      Abbreviations:

      cART (combination antiretroviral therapy), CHPPG (Canadian HIV Pregnancy Planning Guidelines), CS (Caesarean section), HIV (human immunodeficiency virus), HPV (human papillomavirus), ICSI (intra-cytoplasmic sperm injection), IUI (intrauterine insemination), IVF (in vitro fertilization), PHAC (Public Health Agency of Canada), PrEP (pre-exposure prophylaxis), RNA (ribonucleic acid), SOGC (Society of Obstetricians and Gynaecologists of Canada)
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