Caring for women with HIV: Unique needs and challenges
ABSTRACTWomen infected with human immunodeficiency virus (HIV) have unique needs. Treatment recommendations are the same for men and women, but in women, fertility desires, pregnancy, contraception, and aging must be taken into account in their medical care.
KEY POINTS
- The number of women living with HIV has increased over the past 30 years, and African American women bear a disproportionate burden of disease.
- Women of all ages are at risk of acquiring HIV; therefore, HIV testing should be part of routine care.
- Preconception counseling is an essential component of both primary and preventive care and should be the standard of care for all women of reproductive age with HIV.
- Women with HIV have the same gynecologic problems as all women but may be more vulnerable to certain conditions, such as human papillomavirus infection.
HIV-POSITIVE WOMEN NEED ROUTINE GYNECOLOGIC CARE
It is important for women with HIV to receive routine gynecologic care. Women with HIV have gynecologic problems similar to those of all women; however, they may be more vulnerable to certain conditions such as human papillomavirus (HPV) infection, which may be related to HIV disease or associated immunosuppression. In addition, pregnancy and family planning pose special challenges in this group.14
Cervical cancer screening
Effective screening and timely treatment of precancerous cervical lesions are key in preventing cervical cancer in women with or without HIV.
Persistent infection with HPV is necessary for the development of precancerous lesions as well as invasive cervical cancer. Most new cases of HPV infection in the general population resolve spontaneously within 2 years. However, in HIV-infected women, HPV infection is more likely to persist and progress to precancerous lesions of the cervix. This association is strongest in women with more compromised immune function as reflected by low CD4 cell counts and high viral loads.14 Women with HIV have higher rates of infection with high-risk HPV strains and of cervical intraepithelial neoplasia compared with their HIV-negative counterparts.14 The incidence of cervical cancer is five to six times higher in HIV-infected women in the United States than in the general population.15
According to guidelines from the Infectious Diseases Society of America,16 the American College of Obstetricians and Gynecologists,10 the CDC,17 and the American Cancer Society,18 all HIV-infected women should undergo cervical Papanicolaou (Pap) screening upon initiation into care, and this test should be repeated at 6 months and then annually if the results are normal. Patients with abnormalities on the Pap test should undergo colposcopy and, possibly, also biopsy. These abnormalities include atypical squamous cells of unknown significance and higher-grade lesions.16
Nearly one-fourth of HIV-positive women do not receive annual Pap smears despite engagement in care.19 This is unacceptable, because half of the cases of cervical cancer diagnosed in the United States are in women who never received appropriate screening, and an additional 10% are in women who have not been screened in the previous 5 years.19
In HIV-infected women who have had a total hysterectomy, whether to continue Pap testing depends on their history before the surgery. Continued vaginal Pap smear screening is recommended after hysterectomy (including removal of the cervix) in HIV-infected women who have a history of cervical intraepithelial neoplasia grades 2 or 3 or invasive cancer.10,17,20
TREATING HIV IN WOMEN: SPECIAL CONSIDERATIONS
Because it is not yet possible to eradicate the HIV virus, the goals of antiretroviral therapy are to reduce HIV-associated morbidity and mortality, to restore and preserve immune function, to suppress viral load, and to prevent sexual and, in women, perinatal transmission of the virus.21
Antiretroviral therapy is recommended for all HIV-infected patients regardless of the CD4 count, although the strength of recommendation is weaker with higher CD4 counts (Table 3).21 The recommendations for starting antiretroviral therapy and the goals of treatment are the same for men and women. Table 4 summarizes the recommendations for adolescents and adults who are new to treatment.21 For women, additional factors that should be taken into account when considering a regimen include pregnancy potential and whether the drugs chosen for the regimen are considered safe in pregnancy.
Since the early years of the HIV epidemic, researchers have debated whether women attain the same benefits from antiretroviral therapy as men. US Food and Drug Administration investigators performed a meta-analysis of the efficacy outcomes in women in studies of antiretroviral drugs published between 2000 and 2008. They included randomized clinical trials reporting at least 48-week efficacy outcomes, with viral suppression defined as HIV RNA less than 50 copies/mL. The combined database included 40 trials of 16 drugs from 7 drug classes with a total of 20,328 HIV-positive participants. Overall, there were no clinically or statistically significant differences between the sexes in 48-week efficacy outcomes or in rates of trial discontinuation due to adverse events, loss to follow-up, or death.22
Antiretroviral therapy may, however, cause different adverse effects in women than in men. For example:
Nevirapine, a nonnucleoside reverse transcriptase inhibitor, has been associated with the development of a rash and potentially life-threatening hepatotoxicity, more commonly in women than in men and at lower CD4 counts in women. This resulted in recommendations21 to avoid starting a nevirapine-containing regimen in women with CD4 counts greater than 250 cells/mm3 and in men with CD4 counts greater than 400 cells/mm3.
Ritonavir has been observed to cause a higher incidence of nausea and vomiting in women and a higher incidence of diarrhea in men. These are thought to be due to differences between men and women in weight and pharmacokinetics.23
PRECONCEPTION COUNSELING FOR HIV-POSITIVE WOMEN
Preconception counseling is an essential component of both primary and preventive care and should be considered the standard of care for all women of reproductive age who have HIV.24 Health care providers who fully understand the impact of HIV infection and associated comorbidities upon a woman’s reproductive health, fertility desires, and family planning needs are better prepared to assist in their patients’ reproductive health decisions.
The first few weeks of pregnancy are the most critical period in fetal development. During this time, a woman should be healthy and avoid any activities or substances that could cause adverse maternal or fetal outcomes. However, most patients present for prenatal care after this critical time period—thus the need for preconception counseling. Both the Infectious Diseases Society of America and the HIV Medicine Association recommend that all HIV-infected women of childbearing age be asked about their pregnancy plans and desires at the start of care and routinely thereafter.16
The goals of preconception care in women with HIV are to prevent unintended pregnancy, optimize maternal health before pregnancy, optimize pregnancy outcomes for mother and fetus, prevent perinatal HIV transmission, and prevent HIV transmission to an HIV-negative partner when trying to conceive.24
