Concomitant contraceptive implant and efavirenz use in women living with HIV: perspectives on current evidence and policy implications for family planning and HIV treatment guidelines.

IntroductionPreventing unintended pregnancies is important among all women, including those living with HIV. Increasing numbers of women, including HIV-positive women, choose progestin-containing subdermal implants, which are one of the most effective forms of contraception. However, drug-drug interactions between contraceptive hormones and efavirenz-based antiretroviral therapy (ART) may reduce implant effectiveness. We present four inter-related perspectives on this issue.DiscussionFirst, as a case study, we discuss how limited data prompted country-level guidance against the use of implants among women concomitantly using efavirenz in South Africa and its subsequent negative effects on the use of implants in general. Second, we discuss the existing clinical data on this topic, including the observational study from Kenya showing women using implants plus efavirenz-based ART had three-fold higher rates of pregnancy than women using implants plus nevirapine-based ART. However, the higher rates of pregnancy in the implant plus efavirenz group were still lower than the pregnancy rates among women using common alternative contraceptive methods, such as injectables. Third, we discuss the four pharmacokinetic studies that show 50-70% reductions in plasma progestin concentrations in women concurrently using efavirenz-based ART as compared to women not on any ART. These pharmacokinetic studies provide the biologic basis for the clinical findings. Fourth, we discuss how data on this topic have marked implications for both family planning and HIV programmes and policies globally.ConclusionThis controversy underlines the importance of integrating family planning services into routine HIV care, counselling women appropriately on increased risk of pregnancy with concomitant implant and efavirenz use, and expanding contraceptive method mix for all women. As global access to ART expands, greater research is needed to explore implant effectiveness when used concomitantly with newer ART regimens. Data on how HIV-positive women and their partners choose contraceptives, as well as information from providers on how they present and counsel patients on contraceptive options are needed to help guide policy and service delivery. Lastly, greater collaboration between HIV and reproductive health experts at all levels are needed to develop successful strategies to ensure the best HIV and reproductive health outcomes for women living with HIV

Concomitant contraceptive implant and efavirenz use in women living with HIV: perspectives on current evidence and policy implications for family planning and HIV treatment guidelines.

IntroductionPreventing unintended pregnancies is important among all women, including those living with HIV. Increasing numbers of women, including HIV-positive women, choose progestin-containing subdermal implants, which are one of the most effective forms of contraception. However, drug-drug interactions between contraceptive hormones and efavirenz-based antiretroviral therapy (ART) may reduce implant effectiveness. We present four inter-related perspectives on this issue.DiscussionFirst, as a case study, we discuss how limited data prompted country-level guidance against the use of implants among women concomitantly using efavirenz in South Africa and its subsequent negative effects on the use of implants in general. Second, we discuss the existing clinical data on this topic, including the observational study from Kenya showing women using implants plus efavirenz-based ART had three-fold higher rates of pregnancy than women using implants plus nevirapine-based ART. However, the higher rates of pregnancy in the implant plus efavirenz group were still lower than the pregnancy rates among women using common alternative contraceptive methods, such as injectables. Third, we discuss the four pharmacokinetic studies that show 50-70% reductions in plasma progestin concentrations in women concurrently using efavirenz-based ART as compared to women not on any ART. These pharmacokinetic studies provide the biologic basis for the clinical findings. Fourth, we discuss how data on this topic have marked implications for both family planning and HIV programmes and policies globally.ConclusionThis controversy underlines the importance of integrating family planning services into routine HIV care, counselling women appropriately on increased risk of pregnancy with concomitant implant and efavirenz use, and expanding contraceptive method mix for all women. As global access to ART expands, greater research is needed to explore implant effectiveness when used concomitantly with newer ART regimens. Data on how HIV-positive women and their partners choose contraceptives, as well as information from providers on how they present and counsel patients on contraceptive options are needed to help guide policy and service delivery. Lastly, greater collaboration between HIV and reproductive health experts at all levels are needed to develop successful strategies to ensure the best HIV and reproductive health outcomes for women living with HIV

Preventing Mother-to-Child Transmission of HIV in Resource-Limited Settings: The Elizabeth Glaser Pediatric AIDS Foundation Experience

Objectives. In September 1999, the Elizabeth Glaser Pediatric AIDS Foundation initiated a multicountry, service-based programmatic effort in the developing world to reduce perinatally acquired HIV infection. We review 6½ years of one of the world's largest programs for the prevention of mother-to-child transmission (PMTCT) of HIV

Programs increasing access to IUDs and IUSs in the USA and in lower- and middle-income countries (LMIC)

Panel presentation at the International Symposium on Intrauterine Devices and Systems for Women\u27s Health Virtual Series

Conceptual framework for the evaluation of RST pilot study and national programme in Zambia, adapted from Asiimwe et al (2012).

<p>Legend: In this context, these themes were understood to mean the following: Learnability: how easy or difficult it was for HCW to learn to perform the RST, perform it accurately and learn about quality control and quality assurance; Willingness: Willingness of the HCW to perform the RST, to take part in the cascaded training i.e. being trained by or training other colleagues; willingness to take part in supervisory and quality assurance activities; Suitability: HCWs’ belief the RST test was relevant to their work and could be successfully integrated into existing services; HCWs’ belief in the appropriateness of the current supporting components of the RST programme i.e. training, supervision and quality maintenance; Satisfaction: HCWs’ satisfaction with the test itself, its impact on workflow and satisfaction with the supporting components of the programme; Efficacy: Ability of HCWs to implement same-visit testing and treatment (STAT), to incorporate the test and to integrate quality assurance and quality control activities into their workflow; Effectiveness: How the organisational and systemic environment, including implementation of policy, guidelines, supply chain and other logistics, impacted on successful delivery of the programme. In addition, how the social context (the community, patients and their partners) influenced programme delivery.</p

Changes in Syphilis Testing before and after RST introduction and perceived effect on workload for different HCW cadres in Zambia.

<p><b>HCW</b>: Healthcare Worker; <b>RST:</b> Rapid Syphilis Test; <b>RPR</b>: Rapid Plasma Reagin; <b>MCH:</b> Maternal and Child Health; <b>BP</b>: Benzathine Penicillin 2.4 mega units IM. *Rollout HCWs used their own initiative in integrating RSTs into facility workflow. RPR confirmation was often done immediately where RPR was available and performed by the same HCW performing RST.</p

Phased changes in syphilis testing and treatment algorithm in Zambia 2009–2012.

<p>Legend: 4Cs: condoms, counselling, compliance, contact tracing, offer HIV test; RPR:Rapid Plasma Reagin; non-treponemal qualitative test; quantitative testing may also be available;RST: Rapid Syphilis Test, a treponemal test;TPHA*:Treponema pallidum Haemoagglutination assay, a treponemal laboratory test;BP: Benzathine Penicillin 2.4 megaunits IM. *The testing algorithm involving TPHA applied to tertiary care centres and was unavailable at sites included in this evaluation.</p

Health care worker and facility data for pilot and rollout evaluation phases.

<p>*ANC (Antenatal Care) worker includes all of the cadres listed below.</p><p>HCW: healthcare worker; CO: clinical officer; LC: lay counsellor; Nu: nurse; LT: laboratory technician/microscopist; MW: midwife; PC: psychosocial counsellor; RST: rapid syphilis test; RPR: rapid plasma reagin test; UHC: urban health centre; RHC: rural health centre; DH: district hospital; Lus: Lusaka; Wes: Western; Sou: Southern; Lua: Luapula; Mon: Mongu; Kal: Kalomo; Man: Mansa.</p><p>^{^}See accompanying paper, Shelley et al., for additional facilities where only costing evaluation was performed.</p><p>Health care worker and facility data for pilot and rollout evaluation phases.</p

What have we learned? Implementation of a shared learning agenda and access strategy for the hormonal intrauterine device

In 2015, a global learning agenda for the hormonal intrauterine device (IUD) was developed with priority research questions regarding use of the method in low- and middle-income countries. In addition, members of the Hormonal IUD Access Group aligned on a strategy to expand access in the context of volunteerism and contraceptive method choice. This article synthesizes evidence generated since then and describes steps taken to address demand- and supply-side barriers to access. Findings demonstrated high continuation rates and satisfaction among hormonal IUD users that are comparable to other long-acting reversible contraceptives (LARCs). Across studies, a sizable number of users reported they would have chosen a short-acting method or no method at all if the hormonal IUD were not an option, which suggests that women did not see the hormonal IUD as interchangeable with other LARC options and thus it may fill an important niche in the market. With several countries now poised to scale up the method, resource mobilization will be key. On the demand side, investments in implementation research will be critical to understanding how best to launch and scale the method, while ensuring the sustainability of multiple quality-assured suppliers with affordable public-sector pricing will be necessary on the supply side