Download Sexually transmitted infections, including HIV

Sexually Transmitted
Infections,
Including HIV:
Impact on Women’s
Reproductive Health
Catherine Ingram Fogel,
PhD, RN, FAAN
Beth Perry Black, PhD, RN
Introduction
• Sexually transmitted infections (STIs)
affect approximately 19 million Americans
every year.
• They account for 87 percent of the top 10
most frequently reported diseases (Cates,
1999).
• One in 4 Americans will contract an STI
during their lifetime (Gonen, 1999).
© 2007, March of Dimes
Introduction (Continued)
The nurse’s role in promoting women’s
reproductive and sexual health:
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Counsel women about STI risk
Encourage risk-reduction measures
Provide education about STI prevention
Be knowledgeable about treatment and
management strategies
© 2007, March of Dimes
Reproductive Health Concerns
• Passing an STI to a fetus or newborn
– Potentially life-threatening health conditions
– Damage to the brain, spinal cord, eyes and
auditory nerves
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Spontaneous abortion
Stillbirth
Premature rupture of membranes (PROM)
Low birthweight (LBW)
Preterm delivery
© 2007, March of Dimes
STI Transmission: Biological
Factors
• Women are more likely to become infected
with STIs than men.
• More than 50 percent of bacterial and 90
percent of viral STIs are asymptomatic and
likely to be undetected in women (CDC, 2006a,
Futterman, 2001).
• Young women are more susceptible than
premenopausal women to HIV and cervical
infections (Varney et al., 2004).
© 2007, March of Dimes
STI Transmission: Social Factors
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Poverty
Lack of education
Social inequity
Inadequate access to health care
Gender-power imbalances
Cultural proscriptions
© 2007, March of Dimes
STI Transmission: Other Factors
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Alcohol use
Drug use
Depression
Sexual abuse
© 2007, March of Dimes
STI Prevention
(CDC, 2006b)
Activities critical to STI prevention and
control:
• Educating those at risk
• Vaccinating pre-exposure
• Detecting untreated cases
• Effectively diagnosing, treating and counseling
• Assessing, treating and counseling sex partners
© 2007, March of Dimes
STI Prevention
(Continued)
Nurses should:
• Provide individual prevention counseling.
• Encourage safer sex practices.
• Suggest strategies to enhance condom
negotiation skills.
• Educate women about dual protection for STI
and pregnancy prevention.
© 2007, March of Dimes
Safer Sex Practices
• Use barrier protection.
• Find out about a sex partner’s past sexual
behavior and STI exposure.
• Avoid partners who have had multiple sex
partners.
• Reduce the number of sex partners.
• Engage in low-risk sex practices.
• Avoid the exchange of body fluids.
• Avoid sexual contact with casual
acquaintances.
© 2007, March of Dimes
Caring for a Woman with an STI
Counseling is essential to:
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Prevent new infections or reinfection
Increase treatment compliance
Provide support during treatment
Assist a woman in discussion with her partner
© 2007, March of Dimes
Caring for a Woman with an STI
(Continued)
• Nurses are legally responsible for reporting
reportable diseases and must know state
reporting requirements.
– Chlamydia is reportable in most states.
– Gonorrhea, syphilis, HIV and AIDS are
reportable in all states.
• Nurses must inform the woman when an
STI will be reported.
© 2007, March of Dimes
Cervicitis: Chlamydia
• The most common and fastest spreading
STI in American women (CDC, 2002d, 2006b).
• Up to 80 percent of infections are
asymptomatic (Faro, 2001).
• Prevalence in pregnancy ranges between 2
percent and 21 percent (Faro, 2001).
© 2007, March of Dimes
Chlamydia: Pregnancy and
Newborns
Pregnancy complications: Neonatal complications:
• PID
• Acquires infection from
• Postpartum or
mother
postabortion
• Infections to the
endometritis
mucous membranes of
and salpingitis
the eye, oropharynx,
urogenital tract and
• Preterm delivery
rectum
• PROM
• LBW
• Stillbirth
• Ophthalmia neonatorum
© 2007, March of Dimes
Cervicitis: Gonorrhea
• An estimated 1 million Americans contract
gonorrhea each year (CDC, 2002e).
• Most infected individuals are 20 years old
or younger (CDC, 2002e).
© 2007, March of Dimes
Gonorrhea: Pregnancy and
Newborns
Pregnancy complications:
• Chorioamnionitis
• Intrauterine growth
restriction (IUGR)
• Pelvic abscess or
Bartholin’s abscess
• PID
• Postpartum sepsis
• Preterm delivery
• PROM
• Spontaneous septic
abortion
© 2007, March of Dimes
Neonatal complications:
• Acquires infection from
mother
• Ophthalmia neonatorum
• Sepsis
Pelvic Inflammatory Disease (PID)
• Caused by a variety of infectious agents.
• Results from the ascending spread of
microorganisms from the vagina and
endocervix to the upper genital tract.
• More than 1 million women in the U.S.
experience an episode of PID every year;
at least 25 percent of these women
experience long-term sequelae (CDC,
2006b).
• Teenagers have the highest risk.
© 2007, March of Dimes
PID: Pregnancy and Newborns
Pregnancy
complications:
Neonatal
complications:
Ectopic pregnancy
• Fetal wastage
• Infertility
• Inflammatory disorders
of the upper genital
tract
• Maternal morbidity
• Preterm delivery
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•
© 2007, March of Dimes
Acquires infection
from mother
• Death
Ulcerative Genital Infection:
Syphilis
• An estimated 40,000 cases of primary and
secondary syphilis in the U.S. each year
(ASHA, 2005).
• Rates are 16 times higher for AfricanAmericans than for White Americans (ASHA,
2005).
• Other STIs affect mostly teens and young
adults; syphilis persists into the early 30s.
© 2007, March of Dimes
Syphilis: Pregnancy and Newborns
Pregnancy
complications:
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Preterm labor
Spontaneous abortion
Stillbirth
© 2007, March of Dimes
Neonatal
complications: (March of
Dimes, 2005):
Acquires infection from
mother
• Blindness
• Bone and tooth
abnormalities
• Brain damage
• Hearing loss
• Death
•
Ulcerative Genital Infection:
Genital Herpes Simplex Virus (HSV)
• Affects an estimated 50 million Americans.
• Initial infection lasts about 3 weeks.
• Pregnant women with an active, visible
lesion should be screened.
• If lesions or prodromes are not present at
onset of labor, vaginal delivery is acceptable.
© 2007, March of Dimes
HSV: Pregnancy and Newborns
• Maternal complication: Cesarean delivery
if there are prodromes or active lesions
when the woman goes into labor
• Neonatal complications:
– Acquires infection from mother; rates are
highest when herpes is acquired near time of
delivery
– Eye infections
– Severe disseminated or CNS infection resulting
in mental retardation or death
© 2007, March of Dimes
Ulcerative Genital Infection:
Chancroid
• Appears mostly in urban areas.
• Is a cofactor for HIV infection.
• An abrasion is necessary for the organism
to penetrate the skin.
• Neonates can acquire the infection from
the mother.
© 2007, March of Dimes
Diseases Characterized by Vaginal
Discharge
• Vaginal discharge and itching are among
the most frequent reasons a woman seeks
help from a health care provider.
• Vaginal discharge resulting from infection
must be distinguished from normal
secretions.
© 2007, March of Dimes
Diseases Characterized by Vaginal
Discharge: Trichomoniasis
• Affects approximately 3 million women
annually (Gorroll, 2001; Hatcher, et al., 2004)
• Pregnancy complications:
– Preterm delivery
– PROM
• Neonatal complications:
– Acquires infection from mother
– LBW
© 2007, March of Dimes
Diseases Characterized by Vaginal
Discharge: Bacterial Vaginosis (BV)
The most common type of abnormal vaginal
discharge in childbearing women (Calzolari et al.,
2000; Varney et al., 2004)
© 2007, March of Dimes
BV: Pregnancy and Newborns (CDC,
2006b; Koumans et al., 2002)
Pregnancy
complications:
Neonatal
complications:
Chorioamnionitis
• Miscarriage
• Postpartum
endometritis
• Preterm labor and
delivery
• PROM
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•
© 2007, March of Dimes
Acquires infection from
mother
• Infections
• LBW
Vaginal Discharge: Vulvovaginal
Candidiasis (VVC)
• VVC, or yeast infection, is the second most
common type of vaginal infection in the
U.S. (CDC, 2002e).
• The most common symptoms are vulvar
and vaginal pruritus.
• Discharge is often thick, white, curdy and
cottage-cheese-like.
© 2007, March of Dimes
Human Papillomavirus (HPV)
• The most prevalent viral STI in the U.S.
(Hatcher, 2004; Schaffer, 2003)
• One million new infections yearly (CDC, 2001).
Most are asymptomatic, subclinical or
unrecognized (Hawkins, Roberts-Nichols & Stanley-Haney,
2000).
• More frequent in pregnant than nonpregnant women (CDC, 2001).
© 2007, March of Dimes
HPV: Pregnancy and Newborns
• Pregnancy complications:
– Cesarean delivery
• Neonatal complications:
– Acquires infection from mother
– Juvenile laryngeal papillomata (JLP)
© 2007, March of Dimes
Hepatitis A (HAV)
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The most common form of hepatitis
Acquired through a fecal-oral route
No perinatal transmission (Sinclair, 2004)
Pregnancy complications: Spontaneous
abortion and preterm labor due to
dehydration, fever and hypovolemia
• Neonatal complication: LBW
© 2007, March of Dimes
Hepatitis B (HBV)
• Transmitted through infectious blood or
body fluids.
• Is approximately 100 times more
infectious than HIV (CDC, 2003).
• Neonatal complications:
– Acquires infection from mother
– Life-long carrier
– Liver disease and liver cancer
© 2007, March of Dimes
Hepatitis C (HCV)
HCV is the most common chronic bloodborne infection in the U.S. An estimated 2.7
million persons are chronically infected
(CDC, 2006b).
© 2007, March of Dimes
HCV: Pregnancy and Newborns
• Neonatal complications: 5 of every 100
infants exposed become infected, most
often during or near delivery (CDC, 2006b).
• Breastfeeding does not seem to transmit
HCV; however, HCV-positive mothers
should consider not breastfeeding if their
nipples are cracked or bleeding.
© 2007, March of Dimes
Human Immunodeficiency Virus
(HIV)
• An estimated 17.6 million women
worldwide are living with HIV/AIDS
(CDC,
2002a; NIAID, 2006).
• For many, HIV is treated as a chronic
infection, and it may never progress to
AIDS (Varney et al., 2004).
• The clinical goal is to minimize viral
replication.
© 2007, March of Dimes
Effects of HIV on the Immune
System
• HIV is a retrovirus that targets CD4+
T-cells, depleting the number of cells and
impairing cell function.
• Unimpeded, HIV can destroy up to 1 billion
CD4 cells per day.
• HIV is genetically highly variable, mutating
with apparent ease.
© 2007, March of Dimes
HIV Complications
• Pregnancy complications: Gradual loss of
immune function
– Inability to fight disease
– Increased susceptibility to infections, certain
cancers and other life-threatening problems
• Neonatal complications:
– Acquires infection from mother
– Gradual loss of immune function
© 2007, March of Dimes
HIV/AIDS Epidemiology
• AIDS is the fifth leading cause of death
among women ages 25 to 44 in the U.S.,
and the third leading cause of death in
Black women in this age group (CDC, 2002a,
2007b).
• Seventy-nine percent of women with AIDS
in the U.S. are African-American or
Hispanic (CDC, 2007b; NIAID, 2006).
© 2007, March of Dimes
HIV Testing: Pregnant Women
• Include HIV testing in routine prenatal screening.
• Screen after the woman is informed that testing
will be done, unless she declines (CDC, 2006b; 2006c).
• Separate consent for HIV test is not required.
• Repeat screening in the third trimester for women
at high risk or those living in areas with elevated
rates of HIV infection in pregnant women.
• Provide oral and written information to women.
© 2007, March of Dimes
Posttest Counseling:
The Seropositive Woman
• Most HIV+ women are diagnosed during
childbearing years (CDC, 2002e; 2002f; 2006c).
• Making the decision to become pregnant
or forego future childbearing should occur
only after the woman is fully informed
about HIV and pregnancy.
• The antiretroviral zidovudine (ZDV) given
in pregnancy has reduced perinatal
transmission to low levels.
© 2007, March of Dimes
Posttest Counseling:
The Seronegative Woman
• Seronegative women should receive
counseling and education about behavior
change to reduce the risk of contracting
HIV.
• If indicated, serial testing should be
encouraged.
© 2007, March of Dimes
Modes of HIV Exposure
(Jacobson & Hicks, 2000)
• HIV is transmitted through:
• Sexual contact with vaginal and cervical
secretions and semen
• Infected blood, blood components and
clotting factors
• Vertical transmission to the fetus or to the
infant through breastfeeding
© 2007, March of Dimes
HIV in Pregnancy
• The baseline rate of perinatal HIV
transmission without prophylactic therapy
is approximately 25 percent (Anderson, 2001).
• Perinatal transmission rates drop to <2
percent with prophylactic administration
of antiretroviral drugs ZDV and AZT,
scheduled cesarean section delivery and
avoidance of breastfeeding (CDC, 2006b).
© 2007, March of Dimes
HIV in Pregnancy
(Continued)
• Cesarean delivery is recommended as an
intervention to prevent perinatal HIV
transmission only during the active stages
of HIV in untreated women (Public Health Service
Task Force, 2002).
• When replacement feeding is possible,
HIV+ mothers should avoid breastfeeding
(WHO et al., 2003).
© 2007, March of Dimes
HIV Treatment Resource
For free, 24-hour clinical advice for treating
HIV-infected pregnant women and their
infants, call:
The National Perinatal HIV Consultation
and Referral Service
1-888-448-8765
© 2007, March of Dimes
Antiretroviral Therapy (ART)
• Effective ART uses a combination of
antiretroviral therapies (cART) that slow
viral replication.
• Providers should offer cART to all women
who show signs of HIV disease progression
or AIDS-defining criteria.
© 2007, March of Dimes
Antiretroviral Therapy (Continued)
Eleven anti-HIV drugs are approved for use
with pregnant women (Perinatal HIV Guidelines Working
Group, 2006). These include:
• Nucleoside/nucleotide reverse transcriptase
inhibitors (NRTIs)
• Protease inhibitors (PIs)
© 2007, March of Dimes
Adherence to ART
• A critical nursing challenge is to teach and
counsel HIV+ women to adhere to their
prescribed regimen.
• Failure to adhere results in:
– Rapid increase in viral load
– Concurrent immune-system damage
– Risk of developing a resistant strain
© 2007, March of Dimes
Prevention of Opportunistic
Infections
• A single dose of double-strength
trimethoprim-sulfamethoxazole (Septra,
Bactrim) reduces the incidence of
pneumocystis carinii pneumonia (PCP),
toxoplasmosis and bacterial infections (CDC,
1999b).
• It can be used by pregnant women when
the risk of infection outweighs the risk of
the medication.
© 2007, March of Dimes
Prevention of Opportunistic
Infections (Continued)
Nurses should counsel HIV+ women:
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To practice basic hygiene
To eat healthy foods
To exercise
To avoid smoking, drinking alcohol and using
illegal drugs
• To reduce their stress
• To reconsider foreign travel
© 2007, March of Dimes
Summary: The Nurses’ Role
• Respect the woman’s decision about
disclosing her diagnosis.
• Help the woman identify support people
whom she can trust.
• Help the woman reframe her
understanding of HIV and manage it as a
chronic disease.
© 2007, March of Dimes
Summary: The Nurses’ Role
(Continued)
• Nurses must assume a primary role in
helping women decrease risky behaviors
and increase protective practices.
• Education and counseling are essential for
maximum treatment benefits.
© 2007, March of Dimes