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New HIV Therapies Challenge Gynecologic Care : With more than 30 treatment options, obstetricians' knowledge of HIVdrugs should go beyond AZT.


 

HOUSTON — New retroviral therapies are making human immunodeficiency virus infection a chronic disease that physicians need to monitor when providing obstetric and gynecologic care, according to Hunter A. Hammill, M.D.

“You can't work in a vacuum anymore,” Dr. Hammill told clinicians at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

With 30 different treatment options being used in multiple-drug combinations, zidovudine (AZT) should not be the only HIV drug with which ob.gyns. are familiar. “They need to be aware there are many new agents, and with the new agents, it is becoming a chronic disease,” said Dr. Hammill of the Houston-based college.

Today, half of all HIV-infected patients worldwide are women. As people are living longer with HIV infection, the gynecologic patient population now includes postmenopausal women and young women who were infected congenitally.

“I have had patients who should not have lived and now are pregnant teenagers,” he said.

In the United States, he estimated 950,000 people have HIV, but a quarter of them do not know they are infected. In addition, some patients will claim not to know about their status rather than tell a sexual partner. Dr. Hammill described one such woman who tested positive after giving birth. It turned out she had participated in an HIV trial he had conducted 5 years earlier.

Some states require pregnant women to be tested for the virus. In Texas, where the conference was held, the law allows disclosure to a patient's spouse without consent, but physicians can “pass the buck” when a patient tests positive by simply notifying the health department, he said.

Even patients who are asymptomatic and not pregnant should be monitored regularly for CD4 count and viral load, according to Dr. Hammill. “The CD4 count is your army,” he said. “The viral load is the enemy's army.”

Typically, an asymptomatic patient will have an intermediate CD4 count between 200 and 350 and a viral load around 55,000, Dr. Hammill said. If the count is lower, patients could be vulnerable to pneumonia and opportunistic infections.

Retroviral treatment can bring a patient's viral load down to less than 50, which is not detectable. This is especially important if surgery is planned, he said, as needle sticks are dangerous to physicians and nurses.

He also urged resistance testing for antibodies to antiretroviral drugs and studies to determine which agents will work against a patient's strain of HIV, as the virus can and usually will mutate after treatment. “If you have resistance testing and they are not resistant to the drug they are on, and the viral load doesn't go down—it is going up—what do you think is happening?” he asked. “They are not taking their drugs.”

Gynecologists also should be on the alert for opportunistic infections that can develop rapidly. “With HIV everything gets accelerated,” he said, directing attention to pneumocystis pneumonia, cardiomyopathy, erosive herpes, and giant condyloma.

Addressing concerns that HIV medications can interfere with the efficacy of oral contraceptives, Dr. Hammill said he prescribes the OCs at higher doses. He also warned of a high incidence of cervical dysplasia and recommended that women with abnormal Pap smears be screened every 3 months, although many insurance companies will not pay for the added tests.

“You would hate to have a woman die of cervical cancer that could have been prevented and her HIV is in remission,” he said.

Finally, he urged physicians to touch women with HIV as they would other patients. “These patients feel very ostracized. All the normal things we do with patients can be done,” he said.

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