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Implications of restrictions on reproductive rights for HIV care in the USA and beyond

6 April 2023. Related: Conference reports, Treatment access, Women's health, Pregnancy, .

Kirk Taylor, HIV i-Base

The impact of recent changes to reproductive rights legislation in the US, following last year’s  Supreme Court decision, was the topic of an important plenary at CROI 2023 . [1] Abortion legislation changes have direct implications for HIV care and research.

In June 2022 the US Supreme Court voted to overturn Roe vs Wade, ending the constitutional right to abortion and allowing states to implement, or reinstate existing anti-abortion law. Dr Denise Jamieson, an obstetrician/gynaecologist and head of department at Emory University examinedthe implications of the Dobbs vs Jackson judgement for people living with HIV in the US. The university is based in Atlanta, a southern state with restrictive abortion legislation.

She used four hypothetical scenarios to illustrate the impact of the recent changes:

Scenario 1: 17 year old woman living with HIV is five weeks pregnant and lives in Georgia

The pregnancy is unplanned and the woman wants an abortion. State law dictates that abortion can only occur after she signs consent and waits 24 hours, her parent or guardian is informed and in the absence of a detectable heartbeat (approximately 6 weeks gestation). The abortion is scheduled and cancelled due to detection of cardiac activity. The next closest clinic is 134 miles away in South Carolina, but the woman has no resources to travel.

With many states imposing restrictive abortion bans, pressure is growing on states that allow procedures as people travel to seek out of state care. Georgia only grants exemptions for medical emergencies, if the pregnancy is medically futile or is the result of rape or incest and it is less than 22 weeks since last the period.

Scenario 2: ART-naive woman living with HIV is six weeks pregnant and lives in Oklahoma

A woman living with HIV and not on ART has a viral load of 150,000 copies/mL and her CD4 count is 50 cells/mm3. She is six weeks pregnant and presents with cryptococcal meningitis. Recommended treatment includes flucytosine which is contraindicated in the first trimester. Both vertical transmission of HIV and potential teratogenic effects are of concern.

State law only allows abortion in medical emergencies to save the life of the pregnant woman. Most drugs have not been tested in pregnancy and safety data are lacking. Without abortion the optimal treatment will be delayed.

It is not clear if this case meets the criteria for medical emergency under Oklahoma abortion law. Should the doctor perform the procedure it is unlikely to be covered by malpractice insurance and could result in criminal sanctions.

Scenario 3: Woman living with HIV is 17 weeks pregnant, experiences PROM and lives in Texas

Woman experiences PROM (preterm premature rupture of membranes) at 17 weeks’ gestation (pre-neonatal viability). Standard of care recommended by ACOG (American College of OB/GYN) is to offer expectant management or abortion due to high risk of adverse outcomes for both the mother and foetus.

Under Texas state law, it is illegal to perform abortion with doctors risking up to two years in jail and a $10,000 fine. The only exception is to save the life of a pregnant woman.

ACOG guidance states that without abortion maternal morbidity may increase. A case series of 28 pregnant people with PROM at <22 weeks pregnancy showed that maternal morbidity was twice as high for those that received expectant management vs those receiving terminations.

Scenario 4: Woman living with HIV diagnosed with liver cancer aged 35 and lives in Alabama

A woman living with HIV is diagnosed with cancer and starts on sorafenib, which is both teratogenic and embryotoxic. Having missed her period she returns and discovers she is five weeks pregnant and wants an abortion.

Alabama state law prevents abortion after conception, except to save the life of the pregnant woman. There are no exceptions for rape or incest and providing an abortion is a crime. The woman travels 128 miles to Georgia but the procedure is cancelled after detection of a foetal heartbeat. Now at seven weeks gestation, her next option is a clinic 250 miles away in Tallahassee Florida.

Cancer care is a big issue after the Dobbs decision. Cancer affects 0.1% of pregnancies and is likely rising due to increasing age of pregnant people. Delaying treatment raises mortality risk and most cancer therapies are not safe during pregnancy. Abortion rates for pregnant women with cancer are between 9 to 28%. State laws prohibiting abortion for pregnant women may lead to increased mortality.

What can be done?

WHO guidelines are clear that access to sexual and reproductive services should be non-coercive and not affected by HIV status. Abortions should be offered in a respectful and non-judgemental manner.

There is not enough data on medical and surgical abortions for women living HIV to identify outcome differences that are linked to HIV status. However, the data does not suggest that abortions are less safe for women living with HIV.

Dr Jamieson discussed five areas to focus on to monitor and mitigate the impact of changes to reproductive rights.

  1. Establish robust national surveillance systems: While the CDC and Guttmacher Institute have collated several decades worth of abortion data, there are many gaps. The impact of changes in reproductive rights legislation should be tracked through the number of medical and surgical abortions performed and the frequency of self-induced abortions changes.
  2. Promote and protect research for pregnant women and people of childbearing potential: abortion research must continue and include implementation studies to improve acceptability (ie reduce pain), improve access to safe abortion and document the impact of legislative change. It is also important to identify funding sources – relatively few donors fund abortion research.

    Removal of legal abortions will likely reduce the number of people of childbearing potential that are eligible for all clinical studies. For example, clinical trials of new antiretrovirals could be more likely to exclude women of child-bearing potential if abortion is not an option.  Selection of clinical trial sites may also be determined by access to abortion services. This will further widen the knowledge gap for the use of medicines for HIV treatment and prevention by people of childbearing potential and pregnant women.

  1. Ensure clinical training for reproductive care that includes abortion: changes to reproductive rights legislation risks creating “maternity care deserts” where there is not sufficient access to OB/GYN trained doctors – particularly trained to perform abortions in an emergency. Increased efforts are required to train and retain doctors in OB/GYN roles.
  2. Promote and engage in reproductive rights advocacy and education through medical training programmes. Currently many students worry about where to train as states implement restrictive policies and deprive them of essential abortion training. Dr Jamieson described the impressive mobilisation of medical students to addressing these social justice issues as a “bright light”.
  3. Promote health equity and reduce disparities: half of people accessing abortion services are below the poverty line and are unlikely to have the resources required for out of state care. These legislative changes are also predicted to further widen racial disparities in healthcare and increase maternal mortality in the US.

Dr Jamieson concluded by saying that the right to abortion is a critical component of HIV care, not just in the US, but globally. This resonated with the comments of the former IAS president Adeeba Kamarulzaman who said that the “US Supreme Court’s ruling on abortion rights will be felt across the world”.

comment

In no uncertain terms, this excellent talk outlined the dreadful repercussions brought about by overturning women’s right to access safe abortion care and, in many states, returning their options to those available before 1973.

This talk focused on people living with HIV but it goes without saying that this legislation disproportionally affects people who are already marginalised in terms of health and social justice in the US.

Although the talk highlights the domestic situation, Dr Jamieson’s closing remarks acknowledged the likely global implications of this legislation.

Global funding by US donors for abortion and reproductive health services is already shaky and blighted by the global gag rule. This bans NGOs who receive US funding from providing abortion services or referrals, and even advocacy for legal abortion. The global gag has been implemented and revoked by successive US governments since President Reagan. A substantial proportion of global HIV funding is provided by the US government.  

Reference

  1. Jamieson DJ. Restrictions on reproductive rights and their impact on people living with HIV. CROI 2023, 19-22 February 2023, Seattle. Plenary presentation 2.
    https://www.croiwebcasts.org/console/player/51663 (webcast)

Reference

  1. Jamieson DJ. Restrictions on reproductive rights and their impact on people living with HIV. CROI 2023, 19-22 February 2023, Seattle. Plenary presentation 2.
    https://www.croiwebcasts.org/console/player/51663

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