EXECUTIVE SUMMARY

Young people living with HIV experience high rates of unintended pregnancy as well as high rates of substance use.

  • Reproductive health providers should screen all patients for HIV because research finds that a significant proportion of HIV-infected adolescents did not know they were infected until they were tested during pregnancy.
  • All contraceptives are safe to use with antiretroviral therapy.
  • Preconception care is essential for people with HIV.

Adolescents living with HIV in the United States are among the groups with the highest rates of adolescent pregnancy. The latest research shows these pregnancies are likely to be unintended.1

“Unintended pregnancies are higher in adolescents, in general and globally,” says Jean Anderson, MD, professor of gynecology and obstetrics and director of the Johns Hopkins HIV Women’s Health Program. “In the United States, it’s in the range of 45% of all [adolescent] pregnancies that are unintended.”

Researchers found 83.6% of pregnancies among HIV-infected adolescents were unintended. Among adult women with HIV in this study, 68.7% experienced unintended pregnancy.

The study was a retrospective analysis of women in Baltimore living with HIV, ages 15 to 24 years at time of pregnancy, from 2003 to 2015. Of the 340 woman cohort, about one in five received a new HIV diagnosis at the time of pregnancy. Among adolescents, nearly 29% were first diagnosed with HIV during their pregnancy.1

“In prior studies of HIV-negative adolescents, we found similar rates of unintended pregnancy,” says Emily Murphy, MD, clinical fellow, internal medicine and pediatrics at Harvard Medical School and resident in pediatrics at Boston Children’s Hospital. “Prior to our study, we found in a literature review a good amount of studies documenting unintended pregnancy among women living with sexually transmitted infections [STIs].”

One-fifth of adolescents with HIV in this study were born with the virus. Their most common HIV risk factor was heterosexual contact. More than one-third of adolescents reported a history of substance use, and adolescents were more likely to report a history of marijuana use. For adolescents, marijuana use was 29.2% vs. 16.9% for adults.

Status Unknown

Researchers identified gaps in care between adolescents and adults with HIV. For example, adolescents are the least likely age group to know their HIV status, Murphy says.

The findings about unintended pregnancy are consistent with general data on adolescents and higher rates of unintended pregnancy, Anderson notes. For instance, unintended pregnancy rates are highest among low-income women, young women ages 18 to 24 years, cohabiting women, and women of color, according to the Guttmacher Institute.2,3

Studies also suggest unplanned pregnancies are prevalent among women diagnosed with HIV in the United States. A study of data from 1986 to 2015 revealed 78.1% of women in HIV care, ages 18 to 44 years, had an unplanned pregnancy.4

“Data and studies suggest that the rate of unintended pregnancy is higher among women with HIV than in the general population, although it’s high in the general population, too,” Anderson says.

One possible issue could be the complexity of maintaining their health and HIV care. “Something that is a real take-home message for people who are dealing with adolescents and adults with HIV is that in some cases, their HIV care takes precedent,” Anderson says. “They are not having the gynecological follow-up that they should. Adolescents can be risk-takers. As they become sexually active, contraception may not be on their minds.”

Reproductive health providers should keep this in mind when they see patients with HIV or HIV risk factors. Dedicated HIV clinics that also offer OB/GYN services might be the best case scenario.

The study results also produced an interesting twist: Even though the women reported high rates of unintended pregnancies, these were largely viewed positively.

“We found that even though there was a high rate of unintended pregnancy, the majority of women were still pleased to be pregnant,” Anderson says. “They didn’t seek termination of pregnancy or anything like that.”

About 83% of both adolescents and adults reported being satisfied with their pregnancies, Murphy says. Their biggest issue was with the timing of the pregnancy.

“How do we help adolescents time pregnancies in a way that is aligned with their reproductive goals?” Murphy asks.

Improve HIV Screening

The high percentage of young people diagnosed with HIV during pregnancy suggests the need for better screening for HIV, along with other STIs, at gynecological and family planning visits. “Everyone, ages 13 to 64, should be tested for HIV at least once,” Anderson says. “We’re still not great at implementing that in routine care settings.”

HIV testing of pregnant patients is routine: “It’s recommended that it be done in every pregnancy as an opt-out test,” she says. “But these women could have been identified earlier, and maybe that would have changed certain things in terms of their health. They may have wanted to delay their pregnancy until they got their HIV under control.”

Also, the latest evidence and science about HIV treatment recommends patients start antiretroviral therapy (ART) as soon as they are diagnosed. Patients no longer should wait until their viral loads reach a specific threshold.

“The goal is to get individuals with HIV virally suppressed to undetectable levels, which is associated with reduction in morbidity and mortality,” Anderson explains. “It’s very unlikely that if the viral load is undetectable that the mother will transmit HIV to her fetus.”

For these reasons, it is important for reproductive health patients to be screened for HIV and referred to a specialist if necessary.

Preconception care is essential for everyone, but especially for those with HIV, Anderson says.

“Talk with patients about their goals and risk behaviors,” Murphy suggests. “Identify the risk of unintended pregnancy.”

Providers should encourage routine HIV testing. “Most family planning clinics do offer the HIV test,” Anderson says. “But risk-based screening doesn’t work very well because most women we see now are infected sexually and not through IV drug use, so they don’t know that they’re at risk because the risk comes from their partner.”

All this points to the need for routine and ubiquitous HIV testing. “You need to think about HIV testing and how anybody who is sexually active is at risk, and obviously someone who has drug-using behavior is at risk,” Anderson says.

Adolescents are more likely to become infected with HIV via heterosexual activity than are adults. “It’s equally important to know when someone who is not infected but is at risk because of behaviors should consider pre-exposure prophylaxis [PrEP], which is very effective at preventing HIV,” Anderson says.

Privacy Is an Issue

Privacy is a complicating factor. For adolescents, this can be difficult because they might be insured through their parents. Even if a rapid HIV test is used and no one has to call or email results, the insurance billing may breach the adolescent patient’s privacy, Murphy says.

In addition to preconception counseling and HIV screening, reproductive health providers should address a post-pregnancy contraceptive plan with this population. “We found a surprisingly low number of adolescents and adults where, at the time of delivery and before discharge, a contraceptive plan was documented,” Anderson says. “It could have been discussed, but it wasn’t documented, which is concerning because a significant proportion did not come to a postpartum visit.”

Since so many of these women already experienced an unintended pregnancy, they were at high risk of another unintended pregnancy. Women with HIV could use any contraceptive method, and none would affect their antiretroviral treatment. “Combined oral contraceptives may have pharmacokinetic interaction with antiretrovirals, but they don’t impact ART effectiveness,” Anderson adds. “They may lower the drug level of hormones — estrogen or progesterone — which could reduce the efficacy of the contraceptives.”

But this does not mean the contraceptives should not be used. There are no clinical data on the efficacy — only data on drug levels. “Some providers possibly may have heard of that, or read about it, or had not used certain hormonal methods,” Anderson says. “But, essentially, all the methods are on the table, and long-acting reversible contraception [LARC] should definitely be considered for adolescents with HIV, as well as those without HIV.”

The researchers found fewer than one-fifth of adolescents received LARC after delivery, despite the postpartum period being an important time to encourage patients to use high-efficacy contraception.1

Another advantage to LARC for women with HIV is they already are on a daily ART regimen and might be interested in a contraceptive method that does not require a daily pill.

“We have several HIV regimens that are only one pill, once a day, so it’s a lot easier than it was, but it’s still challenging,” Anderson says.

“Postpartum contraception counseling should focus on LARCs, introducing that into conversations about contraception planning in the postpartum period,” Murphy says. “LARC is the preferred method for adolescents, and we found that 17% of adolescents with HIV ultimately received LARC.”

REFERENCES

  1. Murphy E, Keller J, Argani C, et al. Pregnancy in an urban cohort of adolescents living with human immunodeficiency virus: Characteristics and outcomes in comparison to adults. AIDS Patient Care STDS 2021;35:103-109.
  2. Guttmacher Institute. Unintended pregnancy in the United States. January 2019.
  3. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med 2016;374:843-852.
  4. Sutton MY, Zhou W, Frazier EL. Unplanned pregnancies and contraceptive use among HIV-positive women in care. PLoS One 2018;13:e0197216.