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.
WHEN HIV-POSITIVE WOMEN BECOME PREGNANT
Screening for HIV during pregnancy
The CDC recommends prenatal screening for HIV in the first trimester or at entry into prenatal care. A repeat HIV test should be offered in the third trimester for women at risk of acquiring HIV, for women who have signs or symptoms of early HIV infection, in health care settings where prenatal testing yields at least 1 case of HIV infection per 1,000 women screened, and in areas of high HIV incidence. If women present to labor and delivery with unknown HIV status, rapid HIV testing should be done.9
If a woman acquires HIV during pregnancy, the infection may not be detected and may be transmitted to the infant at birth. From 2002 to 2006 in New York State, 3,396 HIV-exposed babies were born. Of these, 9 (22%) of 41 infants born to mothers who acquired HIV during pregnancy became infected, compared with 1.8% of those born to mothers who acquired HIV before pregnancy. Maternal acquisition of HIV during pregnancy was documented in only 1.3% of perinatal HIV exposures, but it was associated with 9 (13.8%) of the 65 perinatal transmission cases.34
Providers should be aware of the signs and symptoms of acute HIV infection and should have a low threshold for repeating HIV testing at any time during pregnancy. It has been estimated that 40% to 90% of patients with acute HIV infection experience fever, lymphadenopathy, pharyngitis, skin rash, myalgia, arthralgia, or other symptoms.35 Providers often do not recognize acute HIV infection, however, because the symptoms are similar to those of other common illnesses. Also, some individuals with the condition have no symptoms.
Antiretroviral therapy during pregnancy
In a landmark study, AIDS Clinical Trial Group 076 demonstrated that zidovudine monotherapy given during pregnancy, labor, and delivery and to the newborn reduced the risk of HIV transmission to the infant by 67%, from 25% to 8%.36 Other studies demonstrated that combination therapy further decreased the risk of HIV transmission to 1% to 2%.37
The US Department of Health and Human Services recommends that all HIV-positive women who are pregnant receive effective combination antiretroviral therapy regardless of CD4 count to minimize the risk of mother-to-child transmission.37
The goals of HIV treatment during pregnancy are to maintain the woman’s health, restore her immune system, suppress viral replication, and decrease the risk of perinatal transmission. The preferred antiretroviral therapy for pregnant women differs from that for nonpregnant women and is based on evolving experience and information about safety, efficacy, and tolerability in pregnancy (Table 8). A woman who presents for prenatal care on a suppressive regimen should continue that regimen as long as she can tolerate it because there is a risk of losing virologic control when switching regimens, and this may increase the risk of perinatal transmission.37
Physiologic changes that occur during pregnancy may alter drug disposition, which could potentially lead to decreased drug exposure. Some of the changes include an increase in total body water, decreased protein binding, induction of hepatic metabolic pathways, and increased clearance of drugs eliminated by the kidneys.38 These changes may be associated with incomplete virologic suppression, virologic failure, or development of drug resistance, so altered doses of some antiretroviral drugs or careful monitoring of viral load should be considered, particularly in the second and third trimester.
Delivery
Women who have a viral load greater than 1,000 copies/mL near the end of pregnancy should undergo a cesarean delivery at 38 weeks and, before surgery, should receive intravenous zidovudine to reduce the risk of perinatal transmission. For women with viral loads below the threshold of 1,000 copies/mL, there is no proven added benefit to cesarean delivery, and in this situation it should be performed only for standard obstetric indications. Antiretroviral regimens should be continued during labor.37
HIV IN OLDER ADULTS
By 2015, approximately 50% of people with HIV will be over age 50.39 Unfortunately, older people and their providers often underestimate their risk of acquiring HIV. Many older people are newly single and may engage in sexual activity with new partners. Also, older people may be reluctant to use condoms as the need for contraception is past.40,41
Baseline HIV RNA levels tend to be higher and CD4 cell counts lower in patients diagnosed with HIV at older ages. These observations support previous ones that older HIV-infected patients may have advanced HIV disease at the time of diagnosis, perhaps in part due to delayed testing.42 Other possible factors are limited income, comorbid illness, polypharmacy, and insufficient data on drug interactions in the elderly.41,42
A prompt diagnosis is important for older patients because HIV may accelerate aging, and aging may speed up HIV progression. Studies have shown that aging is associated with more rapid progression to AIDS, particularly among people who are older than 40 at seroconversion.43 Other studies have reported that older patients have better virologic responses to antiretroviral therapy but have a blunted immune response, more AIDS-defining events, and a higher mortality rate than younger patients.42
