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Developed by JHPIEGO’s Training in Reproductive Health Project with funding from USAID.

Lesson 10: Summary and Key Issues
Instructor: Jean Anderson, MD

To all of you who have made it to this point, congratulations! This is the final lesson and will be a summary of the key issues we have covered in this course.

Summary of the Problem

The burden of disease, disability and death from HIV/AIDS and from poor reproductive health and other reproductive and sexual issues is large and is greatest in the areas with the fewest resources. At the end of 2001, the total number of adults and children living with HIV/AIDS was 40 million and five million people were newly infected with HIV in 2001. The latest statistics reveal that over half of new infections are in women and about half are in young people between the ages of 15 and 24. HIV/AIDS is reversing decades of progress in healthcare, education and economic growth and stability. Children born to women with HIV are often orphaned because one or both parents have died of AIDS and, without access to antiretroviral drugs, about one-quarter of children born to women with HIV will also be infected. Ignorance, intolerance, violence, and oppression worsen the situation for those already infected and help spread new infections.

In developing countries, poor reproductive health accounts for 36% of total disease burden in women and 12% in men. Poor reproductive health in women includes the risks of pregnancy, childbirth, unsafe abortion, sexually transmitted infections (STIs), cervical cancer, and female genital mutilation. Sexually active adolescents are particularly vulnerable both to poor reproductive health and to HIV/AIDS, because of:

• traditional beliefs and practices;
• general lack of power and control;
• risky behaviors;
• biologic vulnerability; and 
• frequent feelings that they are not vulnerable at all.

A constant theme in the care and support of individuals with HIV and those at risk for HIV is the issue of stigma and violence. This is particularly an issue for women who often have little or no control over their sexual lives and decisions about fertility, have fewer educational opportunities, may have poor nutrition, and generally have lower status socially and economically. The low status of women accelerates the HIV epidemic because women are often unable to negotiate condom use and have no control over their partner’s behavior. Women may become infected through repeated unprotected sexual exposures while trying to get pregnant because often having a large family is expected and not having children may lead to divorce or abandonment. 

Men are also at risk of stigma and violence. Men who have sex with men are at increased risk of HIV and often experience stigma and violence. Because of the stigma associated with HIV, many people refuse to be tested and therefore, do not know that they are infected. Once a man or woman is determined to be HIV-positive they may be reluctant to disclose their status to their partner, family or friends for fear of rejection or abandonment. Fear of stigma and violence can make HIV-infected individuals reluctant to seek care and leads to ongoing transmission.

Reproductive issues of special importance in caring for individuals who are HIV-positive include:

• Identification of HIV
• Prevention of HIV
• Family Planning
• Other Reproductive Health Issues
• Mother-to-Child Transmission of HIV
• Infection Prevention

Key Reproductive Issues

Identification of HIV

In order to provide the best care to people with HIV/AIDS, it is important to know that they are infected. However, you cannot tell who is HIV-infected by looking at them, and many individuals who are HIV-infected have no idea that have ever been at risk for HIV. 

There are benefits to knowing one’s HIV status, even in areas with few resources. In relation to reproductive health, these include the ability to make informed decisions about childbearing, helping to prevent MTCT, prevention of sexual transmission to partners, and the ability of healthcare providers to better prevent or manage certain reproductive health problems. In addition, even in limited resource areas, there are usually basic medications available to treat or prevent some of the most common opportunistic infections, such as tuberculosis (TB). As antiretroviral drugs become available in these settings, diagnosis of HIV will be essential to have access to these therapies. 

In areas with limited resources for testing, there may be a need to target these resources to individuals who are at increased risk for HIV. This includes those seen in clinics for sexually transmitted diseases, postabortion care, adolescents; drug and alcohol treatment programs; TB clinics; prisons; and clinics targeting men who have sex with men. In other settings, personal risk assessment can help target HIV counseling and testing resources to higher risk groups. A woman who is pregnant is considered a high priority for offering HIV testing because of available interventions to prevent mother-to-child transmission (MTCT). 

In populations with high HIV prevalence, however, risk assessment can give a false sense of security because it will underestimate the number of individuals actually infected with HIV. In these populations, ALL sexually active individuals should be considered at risk. 

HIV counseling and testing should be voluntary and confidential. Acceptance or refusal of testing should not affect the quality of care the person receives. Information about the use of HIV counseling, testing and other related services should remain absolutely confidential and results of testing should never be shared with others without the express permission of the individual tested. The general components of HIV counseling and testing include:

• Provision of information about HIV, including dealing with false rumors, myths, and misperceptions 
• Personalized prevention counseling 
• Use of diagnostic HIV tests
• Referrals, as needed, for further care and support for both infected and uninfected individuals

Rapid HIV tests have now been developed and generally provide results in 10-15 minutes. These are simple and relatively inexpensive and are very sensitive. However, because they are less specific than standard assays, positive results with rapid tests require confirmation. All HIV antibody tests will be negative after initial infection occurs until antibodies develop, which generally takes 8-12 weeks. HIV counseling is effective in reducing risk behaviors in both HIV-positive and HIV-negative individuals and in serodiscordant couples. 

Prevention of HIV

Even though HIV is increasingly a treatable disease, there is no cure on the horizon. And, in low-resource settings, which bear the greatest burden of disease, treatment resources remain limited or nonexistent. This makes prevention of HIV infection even more important.

There are three major ways HIV can be transmitted. First of all, HIV is transmitted through parenteral exposure, where there is a break in skin integrity and direct exposure to infected blood or blood products. This can occur with use of an unsafe blood supply, injection drug use, and with needlestick exposures in healthcare workers. The second major mode of HIV transmission is mother-to-child transmission during pregnancy, labor and childbirth, or with breastfeeding. The third major mode is sexual transmission, primarily heterosexual. Globally, it is the most common mode of HIV transmission. There is no evidence that HIV is transmitted by insect bites, kissing or hugging an infected person, touching toilet seats or by sharing eating utensils.

Prevention of HIV is possible and prevention efforts have been successful in several areas with limited resources. Delaying the start of sexual activity, lowering the number of lifetime sexual partners, practicing monogamy and abstaining from sexual activity all will help reduce the risk of both HIV infection and other STIs. On the other hand, certain practices, such as anal sex, dry sex in which herbs or other substances are used to dry the vaginal mucosa, and douching may increase infectiousness and susceptibility. Use of alcohol or drugs increases the likelihood of unsafe sexual practices, because people are less inhibited. Both ulcerative and nonulcerative STIs increase the risk of HIV transmission 2-5 times. 

When they are used consistently and correctly, male and female condoms are the most effective methods in preventing HIV transmission and transmission of most STIs, as well as acquisition of these infections. Dual protection is an important concept and is defined as protection against pregnancy as well as HIV and other sexually transmitted infections. Dual protection can be achieved by avoiding penetrative sex; by practicing mutual monogamy between noninfected partners using an effective method of contraception; by using condoms alone; or by using condoms and another method of contraception. 

Although high-risk groups may be targeted for certain interventions, the general population must also be involved if prevention is to succeed. In working with individuals and communities, it is important to emphasize specific risk behaviors and vulnerability, rather than specific groups. Knowledge and awareness of HIV/AIDS and the scope of the problem are important, but not enough to prevent infection. Individuals need to recognize their own level of risk and learn skills associated with sexual negotiation. Statistics have indicated that men play a critical role in spreading HIV/AIDS and that their attitudes about sexuality and sense of invulnerability put women at risk. Men are also likely to have more sexual partners than women, thus putting them at greater risk of becoming infected and transmitting the virus. Therefore, HIV prevention efforts must target both men and women. Condom promotion is an essential part of any prevention program, but long-term changes in social norms will be necessary to make condom use and other behavioral changes more acceptable. Ultimately, socioeconomic interventions are needed to reduce the vulnerability of women and girls and to protect individuals with or at risk for HIV.

Family Planning

Every woman, whether infected or uninfected with HIV, has the right to decide if and when she wants to become pregnant or whether to continue a current pregnancy. Counseling of HIV-positive clients for family planning should focus on individual client’s needs and situation and should assure confidentiality, voluntary choice, informed consent, and respect for client’s rights and empowerment. In addition to safety and effectiveness of available methods, issues to discuss include the potential effect of each method on HIV transmission or progression, potential risks associated with local genital irritation, interference with menstrual bleeding patterns, and drug interactions.

The same contraceptive methods are available to women with HIV infection as for women without HIV. These include:

• fertility awareness methods (lactational amenorrhea and natural family planning); 
• barrier methods (male and female condoms, diaphragm and cervical cap); 
• spermicides; 
• hormonal contraceptives (oral, injectables, and implants); 
• IUD; and 
• male and female surgical sterilization. 

Emergency contraceptives are methods women can use to prevent pregnancy after unprotected intercourse. Emergency contraceptives are not protective against HIV infection. However, they have a role as a backup contraceptive method (to prevent unintended pregnancy) when the condom slips off or bursts.

Although early data suggested that spermicides containing nonoxynol-9 provided additional protection against HIV, the latest data from placebo-controlled clinical trials show that N-9 does not protect against HIV transmission among women who use large amounts of spermicide on a frequent basis.

Combined hormonal contraceptives have significant drug interactions with several antiretroviral (ARV) agents (e.g., nevirapine, nelfinavir, ritonavir, amprenavir, lopinavir/ritonavir, efavirenz). If an HIV-positive woman is taking one of these ARV agents, an alternative or additional contraceptive method is recommended. 

The male or female condom is the only contraceptive method proven to reduce the risk of all sexually transmitted infections (STIs), including HIV. Consistent condom use should be encouraged with all other methods of contraception. Further data are required before definitive conclusions can be made regarding use of hormonal methods or IUDs and possible increased risk of HIV. 

Other Reproductive Health Issues

Reproductive health problems are common among HIV-positive individuals, especially women. The most common of these reproductive problems include:

• menstrual disorders;
• genital ulcer disease;
• abnormal vaginal discharge; 
• pelvic inflammatory disease; 
• human papillomavirus infections;
• lower genital tract dysplasia; and 
• cancers. 

Infertility also appears to be more common in the presence of HIV infection. Several of these conditions are more frequent or more severe with declining immune function. Others may be associated with HIV because of common sexual or drug-using risk behaviors, weight loss, or other factors. Women with HIV may also have any of the reproductive problems that other women have that are unrelated to HIV status. Simple interventions such as prevention or correction of anemia with menstrual blood loss, syndromic treatment of genital tract infections, and visual inspection of the cervix with acetic acid and immediate treatment are applicable to limited-resource settings and can play a significant role in improving the quality as well as the length of life for persons with HIV. 

Mother-to-Child Transmission of HIV

MTCT is the major cause of pediatric HIV/AIDS. It occurs 15-30% of the time in the absence of breastfeeding and without access to ARV drugs. Breastfeeding increases the overall risk to 30-45%. Several factors have been found to increase the risk of MTCT, including STIs and duration of membrane rupture. The most important of these risk factors appears to be the HIV viral load. The most important intervention to reduce risk of MTCT is the use of ARV agents, which lower viral load both in the plasma and the genital tract. Several short courses of one or two ARV drugs have been shown to significantly decrease risk of MTCT.

Although the benefits of breastfeeding in decreasing infant morbidity and mortality and in birth spacing have been well established, breastfeeding in the setting of HIV infection increases risk of MTCT. Maternal, newborn and breastfeeding characteristics may all affect risk of MTCT with breastfeeding. Current guidelines regarding breastfeeding in low resource settings recommend that women who are HIV-negative or who do not know their HIV status should exclusively breastfeed for 6 months to give their newborn the greatest benefits from breastfeeding and limit the potential risk from unrecognized HIV in the women who have not been tested. Women who are HIV-positive should avoid breastfeeding WHEN replacement feeding is acceptable, feasible, affordable, sustainable and safe. HIV-positive women who choose to breastfeed or for whom breastfeeding is the safest and most appropriate alternative should be encouraged to breastfeed exclusively up to 6 months of the newborn’s life and the transition from exclusive breastfeeding to complete weaning should be kept as short as possible. 

As ARV drugs become more available in low-resource countries, it is important to provide care not just to prevent MTCT but to help infected women live longer and healthier lives. The use of highly active antiretroviral therapy (HAART), usually a combination of three agents, has significantly reduced mortality and morbidity due to AIDS and can lower MTCT rates to as low as 1-2%.

Women who are newly infected during pregnancy or breastfeeding are at increased risk for mother-to-child transmission. It is important to emphasize that a negative HIV test in pregnancy does not mean that the woman cannot become infected! Condoms should be used consistently during pregnancy and in the postpartum period. 

Infection Prevention

The risk of acquiring HIV after a needlestick from an infected patient is about 0.4%. The risk of acquiring hepatitis B or hepatitis C from similar exposures is significantly higher. The likelihood of HIV infection following exposure is affected by several factors: 

• the type of exposure (needlestick, mucous membrane, nonintact skin, or intact skin); 
• type of body fluid (blood, semen and vaginal secretions, and sputum are the body fluids associated with the highest risk of HIV transmission); 
• quantity of blood; 
• disease status of the HIV-infected source patient; and 
• use of post-exposure prophylaxis. 

We can minimize and prevent exposure to HIV and other infections that are spread through contact with infected blood or body fluids by using standard precautions with every patient. These include:

• hand washing or hand hygiene; 
• use of personal protective equipment such as gloves, mask to protect nose and mouth, goggles or face shield to protect eyes; 
• handling and processing instruments safely; and 
• safe disposal of medical waste. 

Post-exposure care should be given when necessary and prophylaxis with antiretroviral drugs should be used when available, based on level of risk.

To be effective, post-exposure prophylaxis should be started immediately, within 1 to 2 hours after exposure, using a four-week regimen of 2 to 3 antiretroviral drugs based on the level of risk. 

Conclusion

As the HIV/AIDS epidemic continues to grow, healthcare providers who give reproductive care in low resource settings will be providing care to men and women with or at risk for HIV infection. It is important to understand the impact of HIV/AIDS on reproductive health and the ways reproductive healthcare providers can help prevent HIV/AIDS and better care for those who are infected.