Medical and surgical abortion for women living with HIV: Cochrane systematic review

Abstract

Background

The World Health Organization (WHO) guidelines for safe abortion recommend medical abortion with mifepristone and misoprostol or surgical abortion with vacuum aspiration or dilation and evacuation as safe and effective options for women. However, no specific clinical considerations are stipulated within these guidelines for women living with HIV. Concerns have been raised that women living with HIV may be at greater risk of adverse abortion outcomes compared to HIV-uninfected women due to immunosuppression, high rates of co-infection with other sexually transmitted infections, and possible contraindications between medications used for medical abortion and antiretroviral therapy regimens.

Objectives

Our primary objective was to assess the effectiveness and safety of medical versus surgical abortion among women living with HIV. Our secondary objectives were to: (1) compare outcomes of medical and surgical abortion between women living with HIV and women without HIV and (2) describe outcomes of medical and surgical abortion among women living with HIV.

Search methods

We conducted our search on 17 April 2018. We searched for all published and unpublished trials and observational studies of medical and surgical abortion among women living with HIV. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform using a combination of terms for abortion and HIV. We searched conference websites for relevant abstracts. We also sought unpublished data stratified by HIV status that could be newly analyzed.

Selection criteria

We considered randomized controlled trials (RCTs), non-RCTs, and observational studies. We considered: (1) studies on the effectiveness and safety of medical versus surgical abortion among women living with HIV; (2) studies comparing outcomes of abortion for both methods between women living with HIV and women without HIV; and (3) studies that described outcomes of abortion among women living with HIV.

Data collection and analysis

One review author screened the titles, abstracts, citation information, and descriptor terms for citations initially identified by the search. We obtained the full-text articles of all potentially eligible studies when these were available. Two review authors independently examined the full-text articles for compliance with the inclusion criteria and determination of final study selection. We planned to conduct meta-analysis if a sufficient number of studies (at least three) addressed the same research question and presented data on sufficiently comparable outcomes.

Main results

Of 3840 records screened, we identified just one conference abstract that met our inclusion criteria. This prospective cohort study assessed the efficacy and acceptability of home administration of misoprostol for early medical abortion among women living with HIV who were of less than 63 days amenorrhea in Ukraine. Medical abortion was effective in 65 of 68 cases (96%) examined. The small number of failures included incomplete abortion (n = 1), heavy bleeding (n = 1), and ongoing pregnancy (n = 1). There were no serious infections.

Authors' conclusions

Due to the paucity of studies, we were unable to determine if outcome differences exist between women living with HIV and women without HIV who undergo medical or surgical abortion. We found no evidence suggesting that medical or surgical abortions are unsafe for women living with HIV. While additional research would strengthen the evidence base, healthcare providers should not be deterred from providing access to safe abortion to their patients living with HIV.

Author(s)

Saleem Haneefa T, Narasimhan Manjulaa, Ganatra Bela, Kennedy Caitlin E

Summary

Medical and surgical abortion for women living with HIV

Review question

We reviewed the evidence regarding the safety and success of medical and surgical abortion among women living with HIV. Our main question was: Are there differences in the safety and success of medical abortion versus surgical abortion for women living with HIV? Our secondary questions were: (1) Do outcomes of medical and surgical abortion differ between women living with HIV and women without HIV?; and (2) What outcomes of medical and surgical abortion have been reported for women living with HIV?

Background

The World Health Organization (WHO) guidelines for safe abortion recommend medical abortion with mifepristone and misoprostol or surgical abortion with vacuum aspiration or dilation and evacuation as safe and successful options for women. However, the guidelines make no specific clinical considerations for women living with HIV.

Study characteristics

The evidence is current to 17 April 2018. Of the 3840 records screened, we identified only one unpublished study that met our inclusion criteria. The intervention focused on women living in Ukraine with HIV undergoing medical abortion at home.

Key results

The quality of evidence was low, but found that medical abortion was successful with no major complications experienced among women living with HIV.

Quality of the evidence

The results from this review do not provide enough evidence to determine if differences exist in abortion outcomes for women living with HIV, but also no evidence was found showing that abortion is unsafe in this population. As it is important for all women to have access to safe abortion to combat the public health threat of high rates of maternal deaths, healthcare providers should not be deterred from providing access to safe abortion to their patients living with HIV.

Reviewer's Conclusions

Implications for practice

While the existing evidence is limited, we found no evidence to suggest that medical and surgical abortions are unsafe and ineffective for women living with HIV. The medical and public health communities should work together to remove barriers and expand access to safe, legal medical and surgical abortions for all women, including women living with HIV.

Implications for research

Future research should report on outcomes following medical and surgical abortion comparing women living with HIV to HIV-negative women. In 2016, the World Health Organization convened a Guideline Development Group (GDG), which included women living with HIV, to develop new evidence-based recommendations on sexual and reproductive health and rights of women living with HIV (WHO 2017), as well as to identify key research gaps (Siegfried 2017). During the meeting, the GDG recommended that national or global abortion registries with anonymized data compare outcomes of abortion between women living with HIV and women without HIV. National abortion registries, or a global abortion registry, would illuminate whether reasons for, and consequences of, medical and surgical abortion differ for women living with HIV. An abortion registry would also allow us to monitor and evaluate whether abortion services are equitably accessible to women regardless of HIV status. Other future relevant research areas identified by the GDG included healthcare providers’ attitudes, knowledge and practices regarding the provision of abortion services to women living with HIV, and barriers and facilitators to accessing abortion services for women living with HIV. These future research areas were proposed in response to reports that women living with HIV continue to experience stigma and discrimination when accessing sexual and reproductive health services (Salamander Trust 2014).

Yet while additional research would strengthen the evidence base for future guidelines, healthcare providers should not be deterred from providing access to safe abortion to their patients living with HIV.

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