Announcer

Welcome to the Academy Exchange HIV today and tomorrow in this podcast host we discuss the latest advances in HIV prevention, care and treatment, as well as examine the societal and systemic issues facing people with HIV. Thank you for joining us.

Bruce

Hello, again, and welcome to episode three of the Academy Exchange podcast, HIV Today and Tomorrow, where we take the latest clinical developments in HIV and turn them into a conversation that's available for a wider audience. Again, my name is Bruce Packett, and once more, I'm the chief executive for the American Academy of HIV Medicine, which is an organization that credentials, educates and advocates for the HIV medical providers treating and preventing HIV in the U.S..

Now, this is a special episode to me, because today we're having a conversation with Dr. William Short, who is the incoming chair of the Board of Directors for the Academy, and who is a real thought leader in the clinical space of HIV and its impact on women. At the Academy, I think we really understand that this was a priority space for provider education. With so much of the focus of HIV prevention in this country being, sort of, trained on men who have sex with men, which of course still remains the most prevalent means of viral transmission. But when it comes to women and HIV, whether they have HIV or at risk of acquiring it, there are a whole host of complicated clinical issues, social issues, and perhaps most pressingly reproductive issues, which I think we'll get to explore today.

So with this organizational priority in clinical education, Dr. Short served as the lead faculty content creator and curriculum developer for HIV in Women Course, which is comprised of eight modules that focuses specifically on women's issues. So if you're a medical provider listening here and looking for clinical training opportunities with some CME that is there. before we start with some questions, I just want to do sort of a more formal introduction here for Dr. Short.

William R Short, MD, MPH, FIDSA is an Associate Professor for Medicine with a secondary appointment in obstetrics and gynecology at the Perelman School of Medicine, University of Pennsylvania. Dr. Short graduated with his Doctor of Medicine degree from Hahnemann University. Subsequently completed an internship, residency and chief residency in internal medicine, followed by an infectious disease fellowship at the MCP Hahnemann University.

Dr. Short serves as the Associate Director of the Penn HIV Clinical Trials Unit, ACTU and the co-director of the Clinical Core of Penn Center for AIDS Research. He maintains two active clinical practices, one in the Penn community practice, and the second one in the Helen O. Dickens OBGYN clinic, where he is involved in the care of pregnant women living with HIV.

And perhaps, as I pointed out, most importantly to us, he is the incoming chair of the board of the Academy. Dr. Short, welcome to the podcast.

Dr. Short

Great. Thank you so much. It's great to be here.

Bruce

Yeah, absolutely. Let's get our conversation started with a big picture look at HIV epidemiology and how women are at risk for HIV. Because as I mentioned in my introduction, there's so much prevention focused on the LGBTQ community, and particularly with men who have sex with men. Can you start us off today fust kind of reminding our listeners about women's risk profile for HIV acquisition? Because women do tend to be less of a focus when we're doing our prevention messaging. What do women need to know about their HIV risk?

Dr. Short

Sure. So I think it's a very important conversation to have. And I agree with every point you said. You know, women make up a smaller percentage in the United States, so somewhere around 20%. But if you look globally, women make up more than 50% of the cases of persons living with HIV. So it really is an important focus.

And I think some of the things you mentioned in your introduction are really critical in that not everyone thinks of women and when they say women, I'm talking about cisgender women as having risks for HIV, when in fact there are a whole host of risk factors. We know from looking at data that the majority of cisgender women acquire HIV through heterosexual sex.

And I think that's one of the things that I constantly am reminding people. So when I'm in the hospital and I see someone, and everyone's done every single test for a woman, and they can figure out why she has X, Y or Z. I remind them that this person is at risk for HIV and they say, “Well, she has no risk factors”. She does, she has sex. 

And I think that that constant reminder really needs to occur because people automatically, like you say, just like you said, associated with MSM, associated with anal sexual encounters. And so I really think we need to change our focus and think of it in that sense that women do acquire HIV largely through heterosexual sex. It's really critical.

Bruce

Yeah, absolutely. And you know, as I would imagine most of our listeners here are aware, we're fortunate in 2022 to have a number of really tailor made antiretroviral therapies available to treat HIV. But usually people who are pregnant and oftentimes women in general are excluded from clinical trials. Right? Creating a real lack of information about the effects of these medications on people who are pregnant or how they work on women who are or may become pregnant.

Can you explain to us a little bit about what sort of problem this creates in effectively treating women in their reproductive years for HIV?

Dr. Short

Yeah, it's another great question. You're full of great questions today. You know, we have a very robust research program. I think everyone knows that. So when a new drug comes to market, you have extensive research done. You have the preclinical research, you have phase one looking at safety and tolerability. Then you have these two and usually two large, large phase three clinical trials that lead to the FDA approval, hopefully, of your product.

What's missing, though, is the really important features of what we need when someone becomes pregnant. And that's pharmacokinetic data looking at drug levels, we know during pregnancy there are a lot of physiologic changes that are normal for a woman or a pregnant person. But what happens with those changes is they bring about lower levels of antiretrovirals and we all know that you need adequate levels to achieve viral suppression. So we do need to look at pharmacokinetic data. 

And then a bigger piece is we're lacking safety. And it's not only safety in terms of birth defects, but it's also safety in terms of does this cause preterm birth, preterm delivery, stillbirth, all these other adverse effects of pregnancy that we typically don't think about. And so because we tend to exclude pregnant persons from clinical trials, or if a person becomes pregnant on a clinical trial, we take them off study, we really wind up having no data.

So when a drug gets FDA approved, you are really waiting for these other things like pharmacokinetic data and safety data. And oftentimes that takes years. So what's happening is, persons are becoming pregnant on these drugs, of which there is no data. You're left with this sort of struggle. What do I do? Unfortunately, what people do is they rush and switch to other drugs, which is a big no no in pregnancy care as well, the more you start switching, you run the risk of changes in tolerability in and on and on and on to the point where the person could potentially lose their viral suppression. So it's really a problem that we encounter.

Bruce

Sure. Now let's bring it down to sort of more of the human level. So a woman who is newly diagnosed with HIV comes into your office and let's say she's in the age of reproduction or may wish to become pregnant. What sort of personal counseling or advice would you offer to that patient?

Dr. Short

Yes. So I think one of the first things that needs to happen in that scenario is, one, you have to have a discussion to let them know that this is an option. You know, because I think we tend not to talk about this. We tend not to say it is okay for you to have a child, because we're so focused on other things. We want to get we want to get the labs done. We want to make sure this person has access to afford the medication, since we want to get the social worker to see, the nutritionist to see, we want to make sure we get that pill, hand it out, and we totally forget about something that's going to happen in the future, like a pregnancy.

So I think the conversations have to be one, instructing the person it is possible that you can have children safely. That is a message that's often lacking and it really needs to happen. Once you do that. And if the person says I don't want to have a child right now, that doesn't mean it's not going to happen in the future. And you have to have those discussions. And so those things really need to occur in the clinic.

And then you need to focus on what data is available with the antiretrovirals that you may be using. Because when you look and compare what's recommended for non-pregnant individuals, it's very different than what's recommended for pregnant individuals. Again, from what I mentioned earlier, it's due to those acquiring those key pieces of data you need for pregnancy.

Bruce

Right. Is it safe to say that a woman who comes into your office and is of reproductive age but says she doesn't think she wants to get pregnant, would you still prescribe a regimen, perhaps, that would be tolerable and safe and effective during pregnancy? Or would you trend more towards those treatments that are recommended for non-pregnant women?

Dr. Short

Another great question. So I sit on the pregnancy guidelines and there is an entire section dedicated in that guideline about shared decision making. And that's really critical. So for providers who care for persons who can get pregnant, it's really important you equate yourself with that document.

Because what it does is it talks about having a discussion with the person in front of you, saying, here's a drug that I think would be good for you. You know, you're sharing that decision. What do you want out of it? I want a once a day pill. I want this. My partners on this drug. But then you're going to share: there's no pregnancy data there, there's no PK data there. And if the person says, I'm willing to accept that risk, then then that's the time to say, okay, here's what we know, here's what we do not know.

I think the best example of this is the approval of the long acting injectable rilpivirine/cabotegravir. We know that when you look at that, there are many individuals who want the injectable because they don't want to have to take oral pills for a wide variety of reasons. A large number of the women I see live with someone who's unaware of their status, so they don't want to have those pill bottles in the house.

So having that conversation with a person ,and I have had that conversation with a patient where I say, there's no data on the cabotegravir portion of this. And the person says, I really, I am so interested in this injectable right now. It's going to fit every other aspect of my life. I’m willing to take that risk. So that's the kind of discussions that really need to happen in the clinic. And I know they're not happening often enough, unfortunately.

Bruce

Yeah, of course. So just kind of weighing all the variables of the patient's interest. Yeah. And I'm hoping we can talk briefly about demographics. How often is this happening? By that I mean how many people with HIV in the U.S. become pregnant and then go on to have live births?

Dr. Short

Sure. So it was estimated a couple of years ago around 5000 women living in the United States give birth. However, we do know and this data is not updated frequently, I think the last cut and look was around 4000. So it's a little lower. And again, it's very region specific. So it's around 4,000 to 5000 per year in the U.S..

Bruce

Great. And do you have a sense of how many perinatal transmissions actually happen from mother to child in the U.S.?

Dr. Short 

So the last data is probably from 2018. We're waiting for 2019. But it's less than 1%. And I say that and I don't want to minimize that because you hear, what, less than 1% and you're like, wow, that's great. But it's not. You know, that still equates to a certain number of what I call missed opportunities.

There is, living in the in the U.S., in a high resource area like we have there's access to all types of services, the Ryan White program, insurance is not a barrier. Lots of other things are barriers like stigma and all the other things that come to mind when someone is not accessing care.

So when I hear those numbers, I still cringe because one transmission is too many. And, like I say, in the field of people who work in this arena, the one thing we're fearful to say is we've achieved success, even saying less than 1% success. Because they're afraid that once we do that, we're going to everyone's guard is going to go down and the rates are going to go up because again, like I said, one transmission is one too many.

Bruce

That's right. You don't want to lose the messaging. Absolutely.

Dr. Short

Exactly.

Bruce

Well, I'm hoping we can get into the science, too, because when you talk about things like seroconversion, HIV transmission, it can be a little complicated. And we want to sort of translate that for a general listenership. Can you try to explain how HIV is transmitted from a mother who previously had HIV, then got pregnant to her baby in that perinatal timeframe? And what kind of clinical interventions can be done to stop that transmission from the HIV positive mother to her unborn child? Because I think you're right, in 2022, there's absolutely zero reason to have a maternal-child HIV transmission.

Dr. Short

No, I agree. So the mechanisms are complicated. You know, what I typically say is when someone's pregnant, you have, three trimesters that you're associated with. We know that the majority of the transmissions occur at birth when there’s separation of the placenta and mixing of the blood. But really, you do have the first the second trimester as well.

And when we think of how the virus is transmitted, we know that largely it's a birth. However, there's one scenario that stands out. And that scenario that stands out is someone who has a seroconversion during pregnancy. So, what that means is someone comes into care, and we know during care you usually get screened at two time points. 

First at entry into care and preferably that's the first trimester. And then there's repeat screening depending on a couple of different criteria at the third trimester. And so that's a seroconversion or an incident or an infant infection during pregnancy is someone who is negative on initial screening and then positive on the initial one. And what happens during that, we think, is that there is such a high viral load where, if you remember, during acute seroconversion can have viral loads in excess of 10 million, that that is enough to actually transmit across to the fetus and cause a transmission.

That's rarer. But again, it's really important. And I think I went on that little sort of side. I sort of got off the path there because I think that is a period when you're taking care of, this is largely talking about people who are living with HIV. But if you're caring for individuals who do not have HIV and they're coming in with all the risk factors you think about or all the different scenarios. So someone coming in with a bacterial STI, inconsistent use of condoms, maybe they're having sexual encounters with someone who's HIV status is unknown. That's a person you really want to talk to you about PrEP. Because giving someone prep and prep is safe during pregnancy, especially the CO formulation of TDF/ FTC that is safe and can prevent that seroconversion.

So that's sort of one whole pathway. And the other pathway is when you're coming through the birth canal, which we typically don't think about. Because there is a way through the genital track, there's secretions, there's blood. So what is done to minimize it? 

If you go back to 1994 when the landmark study, the PACTG 076 trial, was presented, what you saw was they targeted, at that time, at that point when 076, prior to 1994 was being developed, no one really knew how HIV was transmitted. So they said, let's target all the possible ways we think of. Let's target maternal viral load, let's target intrapartum and let's target once the baby is born. So there are three different components.

And so right now we still do a large amount of the same thing, but just a little different. So we put persons who get pregnant on antiretrovirals to bring their viral load down to undetectable. So we call that the treatment as prevention. Right? And we know from work in not perinatal transmission.

Number two, we can give intra partum zidovudine or AZT. And the reason we give that, this often causes a lot of questions and people are unsure of why that happens. The reason we give that is the specific drug that we use, specifically the nucleoside reverse transcriptase inhibitors likes zidovudine, but also some of the pills we give like dolutegravir, actually can cross the placenta to the fetus and cause levels. So in a sense, you're giving pre-exposure prophylaxis. 

And then finally, when you have the birth coming through the birth canal, you give post-exposure prophylaxis. So really that's that's when you look at the 076 protocol. You're taking all the things, treatment as prevention, pre-Exposure prophylaxis and post-exposure prophylaxis to really decrease your rate of transmission. And I'll add one final point is that things are changing in terms of how we prophylax newborns. 

So we are giving zidovudine, most people no zidovudine for 4 to 6 weeks, but things are changing and that we now can identify high risk cases. So person comes into pregnancy care at 27 weeks, we put them on meds, we can get them undetectable. That's great. You got that viral load down where you don't no longer need the cesarean section, but you went through 27 weeks where there was detectable viremia. So that newborn will probably get what we call a high risk protocol where they're given three drugs instead of one and they get a day of life PCRs with HIV screening. So it's a much more aggressive approach. So there's a lot we can do to decrease the perinatal transmission.

Bruce

Got it. That's a that's a great throw answer. Thank you for that.

Dr. Short

I'm sorry. It was long winded, but it's a very complicated process.

Bruce

Yeah, super important stuff to hit on. Now shifting to, there's something out there called the Antiretroviral Pregnancy Registry, which I know is a real passion project for you. Can you maybe just talk for a minute about the registry and why it's important and sort of give our listeners an understanding of the work that goes into that registry?

Dr. Short

Sure. So the antiretroviral pregnancy registry was originally the zidovudine pregnancy registry started in 1989. And what it does is collects data. It collects data on exposure to antiretrovirals. And what's important about this is it’s voluntary and it really requires providers to take the time to report. So what does it do?

So it takes all types of reports. So if your care for someone who is gets pregnant and I will say we're going to we're going to limit the discussion here to HIV, but just know that this also takes into account patients who are on pre-exposure prophylaxis, post-exposure prophylaxis and hepatitis B where you're using drugs. Also report there.

But for the purposes of this. So I'm seeing a woman today in my clinic. She comes into me, she is on, let's just say co formulated bictegravir/TAF/FTC. So what I will do is I will register her, I print out forms. You know, it's very easy to go on. You can, anybody can look it up. So the website is www.apregistry.com. And when you go on there, you would go to the section for health providers and then you can find a whole series of resources.

But one of the resources in there is documentations and forms. So you would print out a form and you would register your patient. And what's key about that is you want to register your patient before a birth occurs. Why is that important? Because the APR takes all types of data, so they will take anything from you. 

And I consider it three ways. They look at prospective reporting, retrospective reporting and those from clinical trials all are important to analyze. But what's really important is the prospective reports, because prospective reports and prospective just means you register the patient before the delivery. If you do that, that will get included in the primary analysis. And the primary analysis looks at the drugs and compares them to two population comparators.

So I usually consider that's the most important thing for me because that's the number I want to change. And what that does is it will add to the number of people we have reporting. So as of right now, this is 2022. You know, we know drugs such as bictegravir/FTC/TAF have been out for a couple of years now.

We still do not have birth defect data on that because we don't have enough people reporting. And I know there are plenty of people out there on this compound who are pregnant, but we need to get more and more people to report this.

So having said that, if I report that and then I report the outcome, this will get included. And this is analyzed every six months to data and compared. And it's really important to have that as a way to have some of that safety data. We need really critical because someone sitting in front of you is going to say, can I take this drug when I get pregnant and you're sitting there, scratching your head saying, no, we don't have data on that.

But we can have data on that if you just take some time and report. And you know, there's great resources. We have a webinar that we recorded, as Bruce mentioned earlier, you can look through that. It is it's time consuming, but it's not that hard to do. It's a few forms to fill out. And I will say, we always talk about getting a bang for your buck. You don't get a buck, but you definitely get a bang. And that is you get the data that you need.

I think and I say talking about biktegravir, that's important. But also the long acting injectables so that everyone's subject we don't have data we don't and it's interesting. We have our data on rilpivirine. What we don't have is data on the cabotegravir. So we absolutely need to get that. So I will say take a few moments. Equate yourself with the APR, what it does. And if you have any questions, you can reach out to me. I'm happy to help because it's really critical to collect this information and this is the only way we're going to collect this information. We need number.

Bruce

It's a really important point, and I'll include your contact information in the podcast notes, Dr. Short. You talked a bit about specific clinical interventions, some of the specific HIV treatment regimens and how they might affect the pregnancy. But I want to get into efavirenz a bit because that's an interesting case, right?

For our listeners, efavirenz that is the brand name of an antiretroviral HIV treatment. Now, what can you say about efavirenz and what are some of the lessons we've learned about efavirenz from the antiretroviral pregnancy registry?

Dr. Short

Yeah. So I mean, I think this is a perfect case. And also dolutegravir, I will say, is also one where everyone was using the drug and then, really, as a result of some preclinical animal studies. And we do know that, we didn't talk about it, but where do we get data on drugs? We look early at animal studies. And we know that animal studies don't always translate into what seeming human. So you want to collect this data. 

But what happened with efavirenz there was a signal or a perceived signal that there was a risk of central nervous system defects. And that led to multiple things, including reclassification of the drug when we use pregnancy categories as a D. 

And therefore that led to selectively restricting the use of a key drug. And at the time, 2006, we had our first single drug regimen, which was Atripla, which had efavirenz in it, and many people restricted anyone who could potentially get pregnant from using that based on this data. And then years later, after multiple different data analysis, more information was collected in the pregnancy registry, a meta analysis, all that came to show that there really was no increase in central nervous system defects and it led to the drug, the change.

But many people were not allowed to use the drug and restricted by providers. So these are the kinds of things that we really need to get a handle on and not have this happen. And one of the best ways is getting those reports in or finding ways to get reports in so we have that data available relatively soon after a drug reaches FDA, it gets its FDA approval.

Bruce

Right. And you kind of already hit on this. But as a care provider for a woman with HIV who becomes pregnant, any other take on messaging about concerns or questions you have about her therapy regimen and then choosing what's best for that woman and her unborn baby? For example, is this a case where you would oftentimes change the regimen? We kind of talked about that earlier, for the pregnant mother in order to better protect that pregnancy.

Dr. Short

Yeah, no, it's a great question. It's also one of the things where I, where we always say, one of the tenets of pregnancy is you do not change. So you don't want to change regimens around during the pregnancy. What you want to do is, have the person come into care, see if they're tolerating it, have a discussion, but really continue them on their regimen.

Because a lot of times what happens is a lot of the organogenesis is done within the first trimester. Not all. There's things like one later on, like CNS development, but you really don't want to change regimens frequently. If someone's tolerating their regimen, that's really critical that they stay on that regimen. Because, again, if you look at that neural tube effect, you're talking within the first 28 days after conception.

So when someone comes at you with ten, 12 weeks, you've already passed that critical time period. A lot of the organs have already formed. So if you're going to worry about, birth defects, you really need to worry about it prior to conception and have those discussions. But typically during pregnancy, the other thing you could do, I'm sorry and left that out is you're worried about neural tube defects or defects like that? Make sure you are able to prescribe for someone a prenatal vitamin with folic acid in it. That's really critical, right? You want to make sure they have that on board. If they've had a previous child with a neural tube defect, they obviously need much higher doses. And your obstetrician or pediatrician who's involved will be available to consult for that.

But basic thing you can do and someone tells me I'm thinking about getting pregnant, first thing I do is write a prenatal with folic acid, that's critical. It's not something you need to wait to see the OB provider for, you can write that, that's critical.  Keeping in mind that divalent cations can chelate with things like integrase inhibitors, so you want to make sure you spaced them out. But other than that you're completely fine too right for that and you really should before they get pregnant because, well again, once someone presents, it's usually after that critical period of neural tube development that you really want to get it on beforehand.

Bruce

Yeah. Thanks for sharing that important point. I also want to talk again about the newer, long acting injectable HIV treatments. You mentioned the lack of data there around pregnant women, but what are, in your opinion, some of the considerations for pregnant women around the longer acting options? If a pregnant woman comes to you and wants to do an injection every month or every other month, what are your concerns or reactions to pregnant women requesting that particular medication?

Dr. Short

So if someone is not pregnant, I have a conversation letting them know, right now there is no data… well, we’re accumulating data. I shouldn't say there's no there's very minimal data. But the minimal data we have looked okay. But again, we know that we sometimes need volumes. You know, we need we need a certain amount of numbers to be able to draw conclusions.

So what I typically say is, are you willing to accept that risk? If they're not, and the guidelines do recommend that if someone conceives on long acting injectable, that you go ahead and put them on a 2 to 3 drug preferred regimen.  That you really should not leave them on that. Now, I will say, keeping in mind that the long acting cabotegravir/rilpivirine, they have very long tails.

So while you may add another drug, that drug is still going to be on board for about 52 weeks, not therapeutic concentrations, but you are still going to be on that through the pregnancy. So for example, when I'm reporting to the pregnancy registry and I'm reporting exposure, I'm going to report exposure to the long acting injectable, both of them as well as then what I put on throughout the pregnancy.

So it's a little different here. So in a sense, you're going to be given five different drugs, right? You're going to be given the injectables at conception. And then whenever you switch, I'm going to add three others. Plus the injectables are still going to be there. So that gets a little tricky. But, again, if you if you're reporting, it's all on the forms and they'll actually walk you through I to report all this and there's always someone readily available to talk with you.

Bruce

Right. Absolutely. Going back to PrEP, because you talked about PrEP and the important role it plays in pregnancy work now. And we've talked a lot about pre-exposure prophylaxis or PrEP in previous episodes of this podcast. And our listeners will hopefully remember that this was first approved a decade ago and when taken appropriately, it prevents a person contracting HIV from sex or injection drug use.

Yet, a decade after its approval, CDC is still telling us that about only 10% of the women who would benefit from PrEP were prescribed PrEP in the U.S. in 2019. Why do you think this percentage is so low? And what can we do differently in the health system to improve this uptake?

Dr. Short

Yeah, I have firsthand experience with I work with a wonderful OB-GYN provider who has really put this in the forefront of her clinic. And she worked very hard to try to understand. And she is scratching our head as well, despite having, someone who meets the profile of who would benefit from PrEP. Someone with the bacteria STI, someone with coming in with syphilis, someone in multiple, sexual partners and you offer them.

And there's just such a lack of risk perception. And I think that to me is one of the bigger things that I'm seeing. And again, we're still doing some work on it, both quantitative and qualitatively looking at why is it that we don't have the uptake like we need to. And again, I think the biggest thing that I can see right off the top of my head when I've had conversations with individuals, is they there's not a perception that there is a risk for HIV acquisition.

And the question is, how do you get past that? It's very hard. I've been told everything. I always quote the year because I've been around from the beginning of the pandemic, maybe not practicing medicine, but, I was in health care and I watched when it was largely something that you saw in in gay men.

And so I still hear from female sometimes, well, I'm not a gay man. Why would I have HIV? And so I'm like, wow, so it brings me back to realize we still have a long way to go. We still have, and despite commercials, if you look online now, there's commercials showing females and males and families and it's still this perception that this is a gay male disease.

Bruce

Yeah. And it's really all on us to keep talking about it.

Dr. Short

Yeah. I would even say take it a step further. A White gay male disease.

Bruce

Mm hmm. Right.

Dr. Short

So we have a lot of work to do. We definitely still have a lot of work to do. I think now.

Bruce

Yeah, 40 years later, and we're still honing our prevention messaging lately. 

Dr. Short

Yeah

Bruce

So just kind of to kind of wrap us up today, any other sort of take home messaging or advice you have for other medical providers about delivering HIV care to women and particularly to women who are or may become pregnant?

Dr. Short

Yeah, I think people, I was one myself. I trained in internal medicine, infectious disease. So, I did not have specific, other than my six week rotation in gynecology and obstetrics. I didn't have specific training. But one of the things when I got out of training, I was listed as the women's doc because of where my funding source came from.

And so I learned over time how to provide really comprehensive care for women, including pregnancy care. So I don’t expect everyone to do that. But one, I think it's important, is sort of one of my, not pet peeves, but sort of one of my things when I see something bad that happened, it's one, not talking about it is not going to make it go away.

Not talking about someone getting pregnant does not mean that someone is not going to get pregnant and then there's going to be a lot of anxiety about what to do. So have the conversation. People are not going to say to you, Can I do this? They're not going to ask you specifically. And if they do, you just say I'm not that provider, but I can get you to someone.

So I think you got to have the conversations. That's one. If you're not sure, number two, refer. There's colleagues like myself, there's OB colleagues. Just refer. I think that also comes up with contraception. When you ask the question, do you want to have a child in the next year? And someone says, absolutely not. And then the conversation stops. 

But really, the conversation should then be, what are you doing to prevent that pregnancy? And if I'm a provider that's not going to insert a Nexplanonr an IUD or give depo, then it should be can I get you to someone who can do that? Or I have someone in my practice or I have an OB-GYN and that needs to happen because again, then you're going to have unintended pregnancies.

And we didn't talk about the here, but rates of unintended pregnancy in the HIV population are really high, higher than the general population. So we do need to have those conversations. And then again, don't be afraid of pregnancy. It's already happened. It's there. You know, I find people get very nervous when they hear the word pregnancy. But reach out to someone who's willing to help you doing it.

And  so that way, if you have a positive outcome for all involved.

Bruce

Absolutely. I always look to end on a positive note. So that's where we’ll close. Thank you so much for this fascinating discussion. Dr. Short.

Dr. Short

No, thank you so much for having me.

Bruce

But sure thing. Bye bye.