1. Module 4
HIV Infection in Women

2. 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

3. 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

4. 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, CDC 2000

5. 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

6. 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. 2001

7. 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. 2001

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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. 1999

14. 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. 1999

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

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

17. 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

18. Pregnancy
Does not appear to accelerate HIV infection

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

20. 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

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

22. 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. 2001

23. 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. 2001

24. 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. 2001

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

27. 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

28. 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:

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