Today we interview Dr. Dwight Rouse, professor of obstetrics and gynecology as well as professor of epidemiology at the Warren Alpert Brown School of Medicine and the Brown School of Public Health. We banter back and forth about his life and career, challenging your professors, and what we should be reading.
Today we go into part 2 of our HIV series, this time focusing on pregnancy and HIV. Check out ACOG CO 752 (Prenatal and Perinatal HIV Screening) and CO 751 (Labor and Delivery Management of Women with HIV).
However, we have to give a major shout out to the OBG Project — their editors have put out an awesome summary of HIV in pregnancy and preventing vertical transmission: Check it out here.
One of the important CREOG points on HIV in pregnancy includes drug interactions. Methergine is metabolized by CYP3A4 enzymes, which may be inhibited by certain antiretrovirals. Thus, methergine should be avoided if possible if encountering postpartum hemorrhage.
Lastly, we wanted to drive home the point again about patient autonomy, especially regarding risk of cesarean delivery. We put the ACOG CO text below for you to chew on!
Today we welcome Dr. Aaron Caughey, chair of the Department of Obstetrics and Gynecology at the Oregon Health and Sciences University. Dr. Caughey talks with us about being grounded, about a legacy, and about musical theatre!
The CDC and USPSTF recommend at least one-time HIV screening in most women. The CDC goes further to recommend up to annual screening in certain high-risk groups, including IV drug users, > 1 sex partner annually or known sex partner with HIV, those who exchange sex for money or goods, and MSM.
Screening is important, because almost 25% of new cases occur in women, and heterosexual intimate contact is the most common form of disease spreading. ACOG subscribes to a philosophy of “opt out” testing, by which HIV screening should be considered routine, with the patient able to opt out. Physicians need to document the reason for this in their notes. Screening tests are broken into rapid and confirmatory. A positive rapid screen should always be followed with a confirmatory test, as the rapid screens have high sensitivity, but lower specificity.
GYN care may vary somewhat with positive HIV status. For Pap smears, PB 167 describes an appropriate algorithm for dealing with initial screening and some positive results:
We spend some time reviewing the treatment of other STIs in the podcast briefly, all of which are reviewed in PB 167 as well. Highlights include:
Using 1 week rather than single-dose metronidazole treatment for trichomonal infections
Re-testing any positive GC/CT testing result at 3 months, due to high risk of re-infection
Screening for most STIs at entry to care for HIV-affected patients.
Birth control is also another important topic for HIV-affected patients. ACOG and the CDC recommend use of dual-contraception — that is, a barrier method and a hormonal method — to prevent viral spread. Certain forms of hormonal contraception may be affected by antiretroviral drugs:
CHCs: The NNRTI non nucleoside reverse transcriptase inhibitor efavirenz and certain protease inhibitors (-navir) may decrease efficacy of combined methods by reducing contraceptive hormone levels; however, they are considered US MEC Category 2.
The exception to this rule is fosamprenavir, as CHCs also lead to decreased levels of this protease inhibitor (US MEC 3).
Etonogestrel implant: Similarly to CHCs, there are theoretical risks in decreased contraceptive effectiveness for patients on efavirenz; however, the implant remains US MEC 2.
DMPA: MEC category 1 for all users, except for those on fosamprenavir; there is limited evidence DMPA decreases fosamprenavir levels like CHCs (US MEC 2).
IUDs: MEC category 1 for all users!
Emergency contraception: for oral medicatons such as levenorgestrel and ulipristal, these should be offered to HIV-affected women as the benefits of emergency contraception are considered to outweigh the risks in this group. Similarly to CHCs, there is theoretical risk of decreased efficacy of these methods among women taking efavirenz.
Finally, in a preview to our next episode, we talk about preconception counseling for HIV-affected patients. The goal for any patient with HIV is to achieve a negative viral load, and for OB-GYNs, this is important to limit vertical transmission. Efavirenz has been associated with neural tube defects, so should be avoided in pregnancy if possible.
Conceiving is safest through artificial insemination. However, if natural conception is desired. OB-GYNs should discuss limiting unprotected intercourse to ovulatory times, and using pre-exposure prophylaxis for the patient, or her partner, in serodiscordant couples. This generally involves a daily regimen of tenofovir/emtricitabine (Truvada) for 1 month prior to, and 1 month after, conception. Risk reduction is estimated to be somewhere between 63-75%, and the best-available data suggests this is likely safe.
Today we continue our interview series with Dr. Mary D’Alton, chair of the Department of Obstetrics and Gynecology at Columbia University. Dr. D’Alton shares with us her serendipitous journey into OB/GYN and MFM, and how she’s very confident in the future of the specialty.