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.
Goal 1: Prevent unintended pregnancy
Nearly half of all pregnancies in the United States are unintended.25 Moreover, the Women’s Interagency HIV Study26 showed that women with HIV are underusing effective contraception. In the Medical Monitoring Project, 85% of the women who had been pregnant since being diagnosed with HIV said that at least one pregnancy was unplanned.27
The consequences of unintended and unplanned pregnancies are serious and add significant burden to women, men, and families. Women who do not wish to become pregnant should be advised to use an effective method of contraception.
Contraception
Contraception use varies worldwide. Factors affecting its use include the methods available, patient choice, current health conditions, religious beliefs, perception of method effectiveness, and side effects.24
The Women’s Interagency HIV Study evaluated trends in contraception use from 1998 to 2010. Condoms were the most common form of contraception, and their use changed little over time. Fewer than 15% of women with HIV used no contraception. The use of long-acting reversible contraception, including injectable progestins, implants, and intrauterine devices, which minimize the need for user adherence, increased among HIV-negative women but not among HIV-positive women.28
The World Health Organization states that all available methods are safe for women with HIV except for spermicides with or without a diaphragm, as there is evidence linking the use of spermicides to an increased risk of HIV transmission (Table 5).29
Some antiretroviral drugs may reduce the effectiveness of some contraceptives (Table 6); however, recommendations are based on pharmacokinetic studies, not on outcome studies. Condoms should be recommended not only to protect against pregnancy, but also to protect against sexually transmitted infections.
Goal 2: Optimize maternal health before pregnancy
Maternal health should be optimized before conceiving to reduce the risk of pregnancy-related morbidities and poor birth outcomes. This includes screening for other infections and ensuring that other comorbidities, such as hypertension, diabetes, substance abuse, and mental illness, are well managed with medications that are safe to use in pregnancy (Table 7).
Goal 3: Prevent perinatal HIV transmission
Educating the patient about perinatal transmission is a fundamental component of preconception counseling. Topics that need to be addressed are transmission risk and methods to reduce the risk, including not breastfeeding after delivery.
Goal 4: Prevent HIV transmission to an uninfected partner when trying to conceive
HIV-discordant couples who desire pregnancy should receive appropriate counseling about methods to minimize risk of transmission to the uninfected partner while trying to conceive. There are a number of effective methods and techniques, which are beyond the scope of this review. Key components of all methods are to screen for and treat sexually transmitted infections in both partners and to use effective antiretroviral therapy and attain maximal viral suppression in the HIV-positive partner.
Antiretroviral therapy for the HIV-infected partner significantly reduced the risk of HIV transmission by 96% in the HIV Prevention Trials Network 052 trial.30 Of note: this reduction was the result of both risk-reduction counseling and antiretroviral therapy. This was the first randomized clinical trial to demonstrate that antiretroviral therapy in those with some preserved immune function (CD4 counts 350–500 cells/mm3) in conjunction with risk-reduction counseling can reduce HIV transmission to an uninfected partner.
Vaginal insemination without intercourse is another option for female-positive couples. The man ejaculates into a condom without spermicide, and the contents are introduced with a non-needle syringe or turkey baster. This can be done at home and confers no risk to the uninfected male partner.31 Chances of pregnancy can be maximized by insemination during the most fertile days of the menstrual cycle.
Preexposure prophylaxis combined with timed intercourse. In a study in Switzerland, the infected male partner was given antiretroviral therapy to suppress his viral load to less than 50 copies/mL for at least 6 months, and luteinizing hormone was measured every day in the urine of the noninfected female partner. When the urinary luteinizing hormone level reached a peak, the woman received a dose of tenofovir in the morning, the couple had unprotected intercourse, and the woman took a second dose the next morning. In 53 cases, none of the female partners seroconverted for HIV.32
Health care providers need to document and update the relationship status, partner HIV status, and fertility desires of their HIV patients, both men and women, on a regular basis. Patient education should include awareness of referrals and options to help safely conceive when desired and achieve effective contraception when not.33
