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Module 4 HIV Infection in Women 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 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 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 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 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 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 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 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 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 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 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 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 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 HIV-Related Gynecological Conditions • • • • • • 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 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 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 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 Antepartum/Intrapartum Management Considerations • • • • 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. 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. 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 1800-258-4263 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. 1999 FDA Pregnancy Categories for Antiretroviral Agents and Associated Medications Category A Controlled Studies Show No Risk Category B Category C No Evidence of Risk in Risk Cannot Be Ruled Out Humans Amphotericin B Abacavir Ganciclovir Azithromycin Acyclovir Indinavir Clindamycin Albendazole Interferons Cyproheptadine Amprenavir*† Isoniazid Didanosine Atovaquone Itraconazole Growth Hormone Cidofovir Lamivudine Metronidazole Ciprofloxacin Lopinavir/Ritonavir Nelfinavir Clarithromycin Nevirapine Nystatin Clotrimazole Pentamidine Rifabutin Dapsone Primaquine Ritonavir Delaviridine Pyrazinamide Saquinavir Dronabinol Pyrimethamine Tenofovir Efavirenz* Stavudine Erythropoietin Sulfadiazine Ethambutol Trimethoprim Fluconazole Trimethoprim/ Flucytosine Sulfamethoxazole Fomivirsen Zalcitabine Foscarnet Zidovudine * Contraindicated in pregnancy † Oral solution only; contains significant amount of propylene glycol Prepared by Christopher W. James, Pharm.D. Clinical Pharmacist, HIV Community Program 5/6/02 Category D Category X Positive Evidence of Risk Hydroxyurea Megestrol Acetate Contraindicated In Pregnancy Oxandrolone Ribavirin Testosterone Thalidomide 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: http://www.hab.hrsa.gov/publications.html]. • Bartlett, J. & Gallant, J. (2001). 2001-2002 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-1Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. [Available on-line: http://www.hivatis.org.] References, cont’ • DeLorenzo, L. (2001). Clinical Nursing Series. Nursing Care of the HIV-Infected Patient. Fourth Edition. Western Schools Press.
