1. HIV and Reproduction Dr Felicia Molokoane 2012

2. Introduction 40 million people are living with HIV/AIDS SA is one of the fastest growing HIV epidemic Majority of HIV infected people are women Now the number has stabilised due to ART's

3. Mode of Transmission Sexual Parenteral Perinatal

4. Outline HIV and gynaecological neoplasia HIV and gynaecological infections HIV and infections HIV and infertility HIV and pregnancy

5. HIV and gynaecological neoplasia HIV infected women are at increased risk for developing low and high grade squamous intraepithelial lesions (LSIL and HSIL), atypia (ASCUS) and carcinoma The high risk types HPV 16 and 18 are highly associated with abnormal cervical smears

6. Human papilloma virus HIV infected women have a higher prevalence of infection with HPV Likely to develop persistent infection with multiple HPV's Higher incidence and prevalence of SIL and likely progression to invasive cancer

7. Human papilloma virus Effect of ARTs on HPV infection and CIN is not yet established ARTs has the potential to prevent progression of HPV infection Screening: – Cervical cytology – HPV DNA screening

8. Human papilloma virus Treatment: – Cryotherapy – Large loop excision of the transformation zone – Cone biopsy – Cure rate >85%

9. Cervical neoplasia Women with HIV are more likely to present with multifocal disease Progress more rapidly to cervical cancer Neoplasia is more likely to recur after treatment Other HPV types are found, 52 and 58

10. Vulvar and perianal pathology HIV infected women are at increased risk of acquiring genital warts and vulvar intraepithelial neoplasia ARTs decreases the risk of these conditions

11. HIV and gynaecological infections Vulvovaginal candidiasis Bacterial vaginosis Genital ulcers PID

12. Vulvovaginal candidiasis Risk factors: – HIV, pregnancy, high oestrogen oral contraceptive, uncontrolled diabetes, broad spectrum antibiotics and long term corticosteroids use Promotes HIV acquisition by causing local inflammation on the vaginal mucosa, this disrupting the epithelium Treatment is usually local or systemic for recurrent or complicated cases

13. Bacterial vaginosis Leading cause of vaginal discharge Increase susceptibility to HIV by 1.4 Treatment: Metronidazole – (2x 1g tablets rectal STAT ) – (2g oral STAT)

14. Genital ulcers Herpes Simplex Virus: – Prevalence is increasing in parallel to that of HIV – Frequent reactivation rate – Treatment with acyclovir for 5 days Syphilis: – Associated with 2.5 increase in acquiring HIV – All individuals with syphilis should be tested for HIV – Treatment is benzathine penicillin

15. Genital ulcers Chancroid: – Associated with 2.3 fold increased risk of acquiring HIV – Multiple ulcers, persist for longer duration – Treatment: Tetracycline for 14 days

16. PID Common causative agents are gonorrhoea and chlamydia Present with higher temperatures Tend to have adnexal masses or tubo ovarian complexes Require surgical intervention

17. PID CDC recommends: – Standard antibiotic regimen – May be febrile for 48 hours – Change the regime after 2 to 4 days

18. HIV and contraception The choice of contraception for HIV infected women is often complicated: – Specific contraceptives and their efficacy in preventing pregnancy – Prevention of transmission of HIV and other STDs – Drug interactions between certain antiretroviral agents and hormonal contraceptives

19. Hormonal contraceptives COCs have decreased contraceptives efficacy when taken with some ART regimens: – Liver enzyme inducing drugs, e.g. Protease inhibitors and NNRTI – Choice COCs with oestrogen profile of >30μg – Combine OCs with barrier methods Transdermal and transvaginal delivery: – Hepatic metabolism is avoided – Use with barrier methods – At risk of VTE

20. Hormonal contraceptives DMPA: – Has no known interaction with ARTs – Unaffected by the liver enzymes – Large numbers of HIV + use DMPA – Evidence that DMPA can affect viral burden – Lavreys et al 2004 notes that the use of DMPA in early HIV-1 infection increases the viral set point and subsequently the viral load for HIV infected women – The risk of low bone density, in long term users

21. Hormonal contraceptives Intrauterine devices: – Levonogestrel intrauterine system and copper based IUDs are highly effective, long term, convenient and safe methods of contraception for many HIV stable women – Less likely to become pregnant – If IUD removed, fertility returns quickly

22. HIV and infertility Treatment of infertility in HIV infected couples has always been controversial The need for infertility services may be high among HIV infected women: – 20% have menstrual abnormalities – Tubal diseases Infertility treatment on HIV serodiscordant couple should be individualised

23. HIV and infertility Induction of ovulation and avoid intercourse: – IUI – IVF or ICSI Sperm washing

24. HIV and pregnancy Many women with HIV are diagnosed during pregnancy 1 in 3 pregnant women Check the ART regimen, because some of the drugs are teratogenic

25. HIV and pregnancy Miscarriages Stillbirth Growth restriction Low birth weight Risk of perinatal transmission

26. Conclusion Most women acquire HIV infection via heterosexual contact More likely to have co-incident gynaecological conditions The incidence and severity of these conditions are related to the immune deficiency Regular gynaecological evaluation should be done in all HIV infected women