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Hiv in Women's Health

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Hiv in Women's Health HIV IN WOMEN’S HEALTH: REPRODUCTIVE HEALTH ISSUES AND PREGNANCY Leah Blythe Ruppe, MS, CNM, WHNP-BC Instructor University of Maryland School of Medicine Department of Obstetrics, Gynecology & Reproductive Sciences Diagnoses of HIV Infection among Female Adults and Adolescents, by Race/Ethnicity, 2010–2014—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. a Hispanics/Latinos can be of any race. Awareness of Serostatus Among People with HIV, and Estimates of Transmission ~20% ~49% Unaware of New of Infection Infection s account for… ~80% Aware of ~51% Infection of New Infection s People Living with New Sexual Infections HIV/AIDS:1,200,000 Each Year: ~50,000 Hall et al, AIDS, 2012. MidAtlantic AETC Heterosexual Transmission Estimates of heterosexual transmission vary broadly, ranging from rates of 1/1000 to 1/100 exposure incidents Risk of transmission increases due to a number of variables, including: High HIV viral load (VL) Acute HIV infection/seroconversion Advanced HIV/AIDS Genital ulcerative disease Uterine bleeding Penile-anal intercourse may present a three-fold greater HIV transmission risk than penile-vaginal intercourse (Cohen et al., 2011) (Patel et al., 2014) (Powers, et al., 2008) MidAtlantic AETC Health Issues for Women Anemia Invasive cervical CA is AIDS Rapid progression of defining abnormal Pap Opportunistic infections Increased PID, STI severity Cervical dysplasia # 1 Persistent vaginal Candida, Candidal esophagitis unresolving HSV lesions Kaposi’s sarcoma less associated with declining common in women CD4 Most OIs are equally Intermenstrual bleeding frequent in both sexes Amenorrhea/anovulation Earlier menopause (ACOG, 2010) MidAtlantic AETC Barriers to Prevention and Treatment • Unequal power in relationship • Undiagnosed HIV • Lack of health care access • Lifestyle (e.g., substance use, sex workers) In one study, neither CD4 at diagnosis nor time from diagnosis to treatment improved over a 16 year period, 1990 – 2006 (Keruly & Moore, 2007) MidAtlantic AETC Pap Testing 6 - 12month interval first year after HIV diagnosis (some experts recommend 2 paps in first year after diagnosis and/or entry into care) Annual screening for life (vs. q3years after 3 neg paps) Sexually active HIV positive adolescents within 1 year of onset of sexual activity (regardless of route of transmission) HPV testing alone is not sufficient; use reflex HPV if ASCUS or greater for women under age 30, co-testing with HPV for women over 30 Any ASCUS or higher Pap requires colposcopy or 6 month re- evaluation Use ASCCP Guidelines for all other management of abnormal Pap Consider anal Pap test, as abnormal anal cytology is reported in up to 26% of HIV-infected women https://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf http://www.asccp.org/Guidelines-2/Management-Guidelines-2 (ACOG, 2010) MidAtlantic AETC Preventing HPV infection Reinforce importance of condom use ! HPV vaccination recommended for all HIV-infected females age 13-26 https://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf MidAtlantic AETC Pap Smear Results for HIV-Infected Women • Abnormal cytology is noted in 30-60% of cases, which is 10-11x higher than the general population • Both the degree of immune suppression and HIV VL affect abnormal cytology • Invasive cervical cancer occurs at higher CD4 counts than other OIs (and is AIDS-defining) • In advanced HIV disease, HPV-related changes increase and lesions appear in the lower genital tract MidAtlantic AETC Pap Smear Management Screening colposcopy is recommended with new CD4 <200 Consider periodic colposcopy after dysplasia treatment Women with HIV more likely to have persistent or recurrent disease after treatment with excision or ablation Women should avoid vaginal intercourse for 2-4 weeks after treatment for CIN due to increased HIV shedding (ACOG, 2010) MidAtlantic AETC Barriers to Appropriate Care of Abnormal Paps Study identified 5 themes: Fear (of cancer, of dying, fear related to prior abuse) Asymptomatic issue until advanced disease Life circumstances Perspective on health and disease Provider attitude and behavior (Abercrombie, 2003) MidAtlantic AETC Contraception and HIV • In general, initiation/continuation of contraception is safe for women with HIV/AIDS (MEC category 1 or 2) – Combined hormonal methods – combined pill, patch, ring – Progestin-only pill – Injection – Depo Provera (DMPA) – Implant – Nexplanon – Intrauterine device – LNG-IUD, Cu-IUD (Curtis et al., 2016) MidAtlantic AETC Contraception and Antiretroviral Therapy • NRTIs – MEC category 1 & 2 • NNRTIs – MEC category 1 & 2 – Efavirenz (caution, interactions may reduce efficacy of hormonal contraceptive (implant, dmpa, pop, chc)) • Ritonavir-boosted PIs – MEC category 1 & 2 – interactions may reduce efficacy of hormonal contraceptive (implant, dmpa, pop, chc) *except with boosted lopinavir • PIs without ritonavir – primarily MEC category 1 & 2 – Atazanavir (caution for use with CHC - increased ethinyl estradiol may increase risk of adverse events – use < 30 mcg pill or alternative) – Fosamprenavir (caution, interactions with hormonal contraception may decrease efficacy of fosamprenavir; this is worse with CHCs than with POCs) *MEC category 3 for use with CHCs – Nelfinavir (interactions may reduce efficacy of hormonal contraceptive (implant, dmpa, pop, chc); also with POCs possible decreased level of nelfinavir) https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf MidAtlantic AETC Contraception and Antiretroviral Therapy • CCR5 Co-Receptor Antagonists – MEC category 1 & 2 • Integrase Inhibitors – MEC category 1 & 2 • Fusion Inhibitors – MEC category 1 & 2 Find up-to-date information on interactions: http://hivinsite.ucsf.edu/insite?page=ar-00-02&post=10&param=21 https://aidsinfo.nih.gov/guidelines/htmltables/3/4664 https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf MidAtlantic AETC Contraception and HIV • Recommendations regarding sterilization (bilateral tubal ligation or Essure) no different for HIV-infected women than for non-HIV infected women MidAtlantic AETC WOMEN AND DISCLOSURE Disclosure is a process, not an act • Over time, more than 70% of HIV+ women in the developed world will disclose to sex partners • A small number – 3% to 10% - will not disclose to anyone • Regret is experienced – but <10% of the time • Length of time since diagnosis and severity of disease are associated with disclosure • The key decision: when and how to disclose WHO 2004 (Serovich et al., 2008) MidAtlantic AETC Issues that affect her decision Timing of diagnosis related to the pregnancy Adaptation to life with a chronic disease Fear of abandonment, need for acceptance Real or imagined violence in the relationship The choice of both partners to engage in unprotected sex No legal obligation for health care provider to disclose HIV status to partners Legal obligation is to advise the patient they should disclose MidAtlantic AETC A Framework for Decision-making • Adjustment to the diagnosis • Evaluation of personal disclosure skills • Evaluating the appropriateness of disclosure • Evaluating the circumstances for disclosure • Anticipating reactions • Identifying one’s motivation for disclosure Kimberly, 1995 WHO 2004 MidAtlantic AETC The Issue of Domestic Violence “Women who reported violence as a result of disclosure in the USA tended to be low socioeconomic status women of color with a history of violence in their relationships.” WHO, 2004 MidAtlantic AETC HIV AND PREGNANCY: TOWARDS THE ELIMINATION OF MOTHER TO CHILD TRANSMISSION Cascade of Events for the Successful Prevention of MTCT of HIV • Prevention of HIV infection in women and girls of childbearing potential • Identification of infection among women of childbearing potential • Assurance of adequate preconception care and family planning services for HIV-infected women • Early identification of HIV infection of pregnant women through universal prenatal screening (Nesheim et al., 2012) MidAtlantic AETC Cascade of Events for the Successful Prevention of MTCT of HIV - 2 • Provision of adequate prenatal care for women who have HIV infection • Maximal reduction of maternal viral load through appropriate use of ARV drugs • Cesarean delivery when maternal viral load is not maximally suppressed • Provision of neonatal ARV prophylaxis • Neonatal replacement feeding as well as maternal support for lactation suppression (Nesheim et al., 2012) MidAtlantic AETC The Gardner Cascade (Gardner et al., 2011) Counseling and Testing ACOG recommends “that females aged 13-64 years be tested at least once in their lifetime and annually thereafter based on factors related to risk.” [Providers] should annually review patients’ risk factors for HIV and assess the need for retesting. Repeat HIV testing should be offered at least annually to women who: are injection drug users are sex partners of injection-drug users exchange sex for money or drugs are sex partners of HIV-infected persons have had sex with men who have sex with men since the most recent HIV test have had more than one sex partner since their most recent HIV test (or, whose partner has had more than one partner!) (ACOG, 2014) MidAtlantic AETC Preconception Care A process, not a single clinical event Optimizing maternal health before conception Effects of HIV and ART on pregnancy Maintaining non-detectable VL prevents both sexual and perinatal transmission Use of ART alone provides a 96% reduction for risk
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