Module 4 HIV Infection in Women

Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff of the Pennsylvania/Mid-Atlantic AIDS Education & Training Center, Delaware Local Performance Site - P. Lincoln, N. Bennett, M.A. Bartkowski Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff of the Pennsylvania/Mid-Atlantic AIDS Education & Training Center, Delaware Local Performance Site - P. Lincoln, N. Bennett, M.A. Bartkowski

Demographics of HIV in Women Fastest growing group in the United States 4th leading cause of death aged 25 to 44 in the United States Disproportionately affects African Americans & Hispanics living on the eastern seaboard CDC-2000 Fastest growing group in the United States 4th leading cause of death aged 25 to 44 in the United States Disproportionately affects African Americans & Hispanics living on the eastern seaboard CDC-2000

Statistics of HIV in Women Cumulative Statistics as of December 2000 in the United States  74,997 African American  28, 151 White  25,643 Hispanic  1,133 Other Total 130, 104 CDC 2000 Cumulative Statistics as of December 2000 in the United States  74,997 African American  28, 151 White  25,643 Hispanic  1,133 Other Total 130, 104 CDC 2000

HIV Transmission Risk Behaviors for Women Heterosexual - 62%  African American - 63%  White - 18%  Hispanic - 18%  Other - 1%  primary risk behavior for all age groups of women IVDU - 35% Other - 3% CDC 2000 Heterosexual - 62%  African American - 63%  White - 18%  Hispanic - 18%  Other - 1%  primary risk behavior for all age groups of women IVDU - 35% Other - 3% CDC 2000

Female Condom “Reality” - only brand currently marketed in the US Made of polyurethane, sheath closed at one end with flexible rings at both ends Anderson, J “Reality” - only brand currently marketed in the US Made of polyurethane, sheath closed at one end with flexible rings at both ends Anderson, J. 2001

Microbicides Strategy enabling women to have control over safer sex/prevention of HIV Nonoxynol-9 increases risk of HIV infection Clinical trials of topical microbicides are being conducted Anderson, J Strategy enabling women to have control over safer sex/prevention of HIV Nonoxynol-9 increases risk of HIV infection Clinical trials of topical microbicides are being conducted Anderson, J. 2001

Gender Bias Transmission More efficient from man to woman than woman to man Related to number of infectious particles in body fluid Related to volume of fluids exchanged Related to surface area coming in contact with infected body fluid HRSA:BPHC & AETC More efficient from man to woman than woman to man Related to number of infectious particles in body fluid Related to volume of fluids exchanged Related to surface area coming in contact with infected body fluid HRSA:BPHC & AETC

Risk Factors for Male to Female HIV Transmission Anal Intercourse Lack of male circumcision Genital ulcers (syphilis, herpes simplex, chancroid) Sexually Transmitted Diseases Multiple sexual partners Anal Intercourse Lack of male circumcision Genital ulcers (syphilis, herpes simplex, chancroid) Sexually Transmitted Diseases Multiple sexual partners

Special Consideration Early Adolescent  immaturity of the female genital track increases risk of transmission Women over 50 years of age  atrophic vaginitis caused by decreased lubrication  older females are generally not perceived to be at risk Early Adolescent  immaturity of the female genital track increases risk of transmission Women over 50 years of age  atrophic vaginitis caused by decreased lubrication  older females are generally not perceived to be at risk

Natural History of HIV Disease in Women Same as in men except for GYN symptoms and disease conditions 1993 CDC added invasive cervical cancer as an AIDS defining condition Women are often diagnosed late Women may have barriers to care HRSA:BPHC & AETC Same as in men except for GYN symptoms and disease conditions 1993 CDC added invasive cervical cancer as an AIDS defining condition Women are often diagnosed late Women may have barriers to care HRSA:BPHC & AETC

Challenges in Caring for Women with HIV Statistically economically poorer than men More likely to be single parents  lack of child care  lack of support More likely to be uninsured HRSA:BPHC & AETC Statistically economically poorer than men More likely to be single parents  lack of child care  lack of support More likely to be uninsured HRSA:BPHC & AETC

Signs and Symptoms of HIV in Women Acute Seroconversion - (No distinct gender differences however many of these s&s often go under addressed)  fever  swollen glands Bartlett, J Acute Seroconversion - (No distinct gender differences however many of these s&s often go under addressed)  fever  swollen glands Bartlett, J. 1999

Signs and Symptoms of HIV in Women cont’  Rash - macular or maculopapular, usually nonpururitic. Truncal / facial distribution can involve arms and legs. Often appears several days past onset of fever.  Fatigue  Mono-spot test is negative  Bartlett, J  Rash - macular or maculopapular, usually nonpururitic. Truncal / facial distribution can involve arms and legs. Often appears several days past onset of fever.  Fatigue  Mono-spot test is negative  Bartlett, J. 1999

HIV-Related Gynecological Conditions Vaginal candidiasis Human Papilloma Virus Genital Ulcers Pelvic Inflammatory Disease Cervical Dysplasia/Neoplasia Menstrual Disturbances HRSA:BPHC & AETC Vaginal candidiasis Human Papilloma Virus Genital Ulcers Pelvic Inflammatory Disease Cervical Dysplasia/Neoplasia Menstrual Disturbances HRSA:BPHC & AETC

Diagnostic Studies Pap smear  two studies the first year of diagnosis  annually if normal  recommended every 6 months if HIV is symptomatic Colposcopy USPHS/IDSA 2001 Pap smear  two studies the first year of diagnosis  annually if normal  recommended every 6 months if HIV is symptomatic Colposcopy USPHS/IDSA 2001

Prenatal & Family Planning HIV Screening DHHS guidelines suggest universal HIV testing with patient notification as a routine component of prenatal care Pre and post test counseling & informed consent - laws vary by state USPHS/IDSA 2001 DHHS guidelines suggest universal HIV testing with patient notification as a routine component of prenatal care Pre and post test counseling & informed consent - laws vary by state USPHS/IDSA 2001

Pregnancy Does not appear to accelerate HIV infection

Perinatal HIV Transmission May Occur Antepartum  during pregnancy Intrapartum  during labor  during delivery Postpartum-through breast feeding HRSA:BPHC & AETC Antepartum  during pregnancy Intrapartum  during labor  during delivery Postpartum-through breast feeding HRSA:BPHC & AETC

Reducing Perinatal Transmission ACTG 076  women given AZT after first trimester  AZT administered intravenously during labor  newborn receives AZT for 6 weeks  transmission reduced by 67.5% Combination therapy has reduced the rate even further HRSA:BPHC & AETC ACTG 076  women given AZT after first trimester  AZT administered intravenously during labor  newborn receives AZT for 6 weeks  transmission reduced by 67.5% Combination therapy has reduced the rate even further HRSA:BPHC & AETC

Antepartum/Intrapartum Management Considerations Avoid amniocentesis Avoid premature rupture of membranes Avoid fetal scalp monitoring Delay episiotomy HRSA:BPHC & AETC Avoid amniocentesis Avoid premature rupture of membranes Avoid fetal scalp monitoring Delay episiotomy HRSA:BPHC & AETC

HIV Medications to avoid during Pregnancy Efavirenz - associated with anencephaly, anopthalmia Neural tube defects in primates Indinavir - Potential for nephrolithiasis and neonatal hyperbilirubinemia DeLorenzo, L Efavirenz - associated with anencephaly, anopthalmia Neural tube defects in primates Indinavir - Potential for nephrolithiasis and neonatal hyperbilirubinemia DeLorenzo, L. 2001

HIV Medications to avoid during Pregnancy, cont’ Didanosine/Stavudine - combination associated with fatal lactic acidosis in pregnancy Stavudine/Retrovir -combination is antagonistic, decreasing efficacy of therapy DeLorenzo, L Didanosine/Stavudine - combination associated with fatal lactic acidosis in pregnancy Stavudine/Retrovir -combination is antagonistic, decreasing efficacy of therapy DeLorenzo, L. 2001

Antiretroviral Pregnancy Registry Collaborative effort between the CDC, NIH and pharmaceutical companies to monitor for birth defects in infants exposed to antiretroviral agents antiretroviral exposure during pregnancy should be reported to the registry at Anderson, J Collaborative effort between the CDC, NIH and pharmaceutical companies to monitor for birth defects in infants exposed to antiretroviral agents antiretroviral exposure during pregnancy should be reported to the registry at Anderson, J. 2001

Current Prevention Message-Is it Reality ? Abstinence Monogamy Reduce number of partners Ask partner about history of infection Enforce use of condoms Colmorgen, G Abstinence Monogamy Reduce number of partners Ask partner about history of infection Enforce use of condoms Colmorgen, G. 1999

References Anderson, J. (Ed.) (2001). A guide to the clinical care of women with HIV. Rockville, MD: HIV/AIDS Bureau, Health Resources and Services Administration. [Available on-line: Bartlett, J. & Gallant, J. (2001) Medical Management of HIV Infection. [Available on-line: http;//hopkins-aids.edu Anderson, J. (Ed.) (2001). A guide to the clinical care of women with HIV. Rockville, MD: HIV/AIDS Bureau, Health Resources and Services Administration. [Available on-line: Bartlett, J. & Gallant, J. (2001) Medical Management of HIV Infection. [Available on-line: http;//hopkins-aids.edu

References, cont’ Center for Disease Control and Prevention. (2002,February). Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1- Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. [Available on-line:

References, cont’ DeLorenzo, L. (2001). Clinical Nursing Series. Nursing Care of the HIV-Infected Patient. Fourth Edition. Western Schools Press.