Slide 2
The goals of healthcare are to identify women in reproductive health
settings who are HIV-infected in order to serve as an entry point for
care; to identify and treat symptomatic gynecologic conditions; to prevent
the development of cervical cancer, the most common gynecologic malignancy
worldwide and an AIDS defining condition in women with HIV; and to prevent
transmission to others, with a focus on prevention of sexual transmission.
Slide 3
Women being seen for reproductive healthcare are generally sexually
active; they may be pregnant or at risk for becoming pregnant; they may
have signs or symptoms of genital tract infections. In areas of high HIV
prevalence, these are women at increased risk for becoming HIV-infected.
Reproductive healthcare should include information and counseling about
HIV and personal risk assessment. Voluntary testing may be performed on
site or clients can be referred for testing. Reproductive healthcare
offers the opportunity to identify HIV infection early, often during the
period of clinical latency, so that appropriate clinical care can be
started at a time it is likely to be most effective, and sexual and
mother-to-child transmission can be prevented.
Slide 4
Contraception for the woman with HIV infection must take into account
the effectiveness of different methods in preventing transmission of
infection, in addition to considerations of contraceptive efficacy,
safety, and potential non-contraceptive benefits. Both male and female
condoms effectively prevent HIV transmission and Sexually Transmitted
Infection or STI acquisition when used consistently and correctly. Female
condoms have the advantage of being female controlled, although they
cannot be used without their partner's knowledge. Although spermicides
have significant activity against gonorrhea and chlamydia and activity in
the laboratory against HIV, their use, particularly if frequent, has been
associated with an increase in mucosal irritation and even genital ulcers.
A recent clinical trial conducted by UNAIDS in Africa and Thailand
actually found significantly increased rates of HIV seroconversion in
nonoxynol-9 users as compared to placebo.
Slide 5
The diaphragm has limited STI protection and no significant protection
against HIV transmission. Use of the Intrauterine Device or IUD in the
setting of HIV infection remains controversial. There has been no increase
in infection-related complications noted in women who are IUD users and
HIV-infected. There has also been no increase in cervical HIV shedding
demonstrated when measured four months after IUD insertion. On the other
hand, the IUD does not offer protection against either HIV transmission or
STI acquisition; furthermore, there are concerns that the increased
menstrual flow and duration seen in non-progesterone- and non-progestin-releasing
IUDs may increase transmission risk or increase the risk of anemia, which
is an independent predictor of progression in HIV disease.
Slide 6
Hormonal contraceptive methods offer no significant STI protection and
there is some data, although inconclusive, that they may increase genital
tract HIV shedding. Voluntary sterilization, although it may reduce the
risk of tubal infection or salpingitis, does not offer other STI or HIV
protection.
Slide 7
The use of condoms for prevention of HIV and STI transmission or
acquisition is more difficult than using condoms to prevent pregnancy. For
effective infection prevention, condoms must be used even when prevention
of pregnancy is not needed, such as in postmenopausal women, during
pregnancy, when the woman or her partner is infertile, or when other more
effective contraceptive methods are used. The concept of dual method use,
in which condoms and a highly effective method of contraception are used
together, provides the best protection against both pregnancy and
infection transmission or acquisition. However, if HIV-infected or
HIV-at-risk women are able or willing to use only one method, male or
female condom use should be emphasized and encouraged.
For condoms to be effective, they should be stored in a cool, dry area,
out of direct sunlight, to prevent deterioration. They must be used
consistently and correctly. Only water-based lubrication or appropriate
spermicide should be used with condoms. Oil-based lubricants, such as
petroleum jelly, cooking oils, shortening, or lotions, result in a 90%
reduction in latex strength in just 60 seconds and promote breakage.
Clients should be instructed in proper use. Common errors in use include
delaying condom application until just prior to full penetration, failure
to extend the male condom all the way to the base of the penis,
insufficient application of a water-based lubricant, and failure to hold
the base of the condom during withdrawal.
Slide 8
There are several gynecologic problems that are common in the setting
of HIV infection, and these often occur when the woman with HIV has no
other symptoms. In one study, almost one-half of HIV-infected women
developed a gynecologic problem over the course of follow-up. Another
study of hospitalized AIDS patients found that 83% of women had coexisting
gynecologic disease. These include menstrual disorders, genital ulcer
disease, abnormal vaginal discharge, pelvic inflammatory disease, and
human papillomavirus infections and lower genital tract dysplasia and
neoplasia. Several of these conditions are more frequent or more severe
with declining immune function; others may be associated with HIV because
of common risk behaviors, weight loss, or other factors.
Slide 9
HIV-infected women frequently report menstrual disorders. However,
controlled studies have given conflicting evidence regarding whether HIV
or HIV-related immunesuppression exerts a clinically significant direct
effect on menstrual function. In any woman with abnormal bleeding or
amenorrhea, the possibility of pregnancy must be considered and ruled out.
Menstrual disorders may also reflect malnutrition, wasting, or chronic
disease in the HIV-positive woman. Women with increased menstrual blood
loss are at risk for anemia, which is an independent predictor of HIV
progression and death, and requires intervention.
Slide 10
What can be done for the HIV-infected woman with abnormal menstrual
function? Iron supplementation, as well as iron-rich foods, can help
prevent or correct anemia with increased menstrual blood loss. Pregnancy
testing should be used when available in order to identify women who are
pregnant and need antenatal care. Women who are pregnant and have lower
abdominal pain and irregular bleeding may have an ectopic pregnancy and
should be followed closely to assess the need for possible surgical
intervention. Underlying STIs, particularly gonococcal or chlamydial
cervicitis or endometritis, may cause irregular bleeding or spotting, and
should be ruled out or treated if present. Cervical cancer may present
with abnormal bleeding and in postmenopausal women with bleeding, uterine
cancer must be considered. Surgical evaluation may be needed. In women
with ovulatory disorders or increase in menstrual flow or duration, use of
hormonal contraception can decrease blood loss and regulate menses.
Ultimately however, surgical treatment may be necessary with severe
menorrhagia that is secondary to uterine fibroids and unresponsive to
simple measures.
Slide 11
STIs and HIV are closely interrelated. The clinical findings of certain
STIs are changed in the presence of HIV. Furthermore, STIs, both
ulcerative and nonulcerative, increase the risk of HIV transmission 2-5
times. Genital ulcers disrupt the epithelial barrier, and STIs also
increase the number of cells vulnerable to HIV in the genital tract,
increasing susceptibility in uninfected individuals. Alternatively,
HIV-infected persons with STIs have increased genital tract HIV viral
load, which increases infectiousness. Treatment of these infections
reduces the amount of virus in the genital tract. These findings suggest
that screening and treating STIs can be another way to prevent HIV
transmission. Indeed, in one clinical trial in Tanzania, enhanced
syndromic management of STIs resulted in a 38% decrease in HIV
seroconversion over two years.
Slide 12
Genital ulcers are most commonly caused by syphilis, chancroid, or
herpes simplex. These etiologies cannot be reliably distinguished from one
another on clinical grounds and may coexist in the same individual.
HIV-infected persons with syphilis may have abnormal serologic results,
such as unusually high titers, false negatives, or delayed seroreactivity,
although generally serologic tests can be interpreted in the usual manner.
The clinical presentation of syphilis is variable at all stages, but
atypical manifestations may be seen in the setting of HIV infection.
Neurosyphilis should be considered in the differential diagnosis when
HIV-infected individuals present with neurologic signs or symptoms.
Therapy is not altered by the presence of HIV infection.
With chancroid, response to treatment may be diminished in the
HIV-infected person; with use of single dose therapies, close follow-up is
necessary since treatment failure may be more likely. Herpes simplex
infections are chronic, involving relapsing infections that cannot be
cured by current therapies, although infections can be controlled by
suppressive or intermittent antiviral agents such as acyclovir. In the
HIV-infected client with genital herpes, more frequent, prolonged, and/or
severe episodes are common with progressive immunesuppression and lesions
may be atypical in appearance or location.
Slide 13
In women with late-stage AIDS, genital ulcers may develop for which no
specific cause can be found. These are known as aphthous ulcers. In about
one-third of cases, oral or esophageal ulcers are present as well, and
one-fifth of cases are also associated with fistula formation, usually
with erosion into the rectum.
Slide 14
Other causes of genital ulcers include lymphogranuloma venereum and
granuloma inguinale, which are caused by infections and may be more
difficult to treat in individuals with HIV infection. With any genital
ulcer that does not heal and does not respond to treatment, a malignant
neoplasm must be considered.
In areas with limited resources for diagnosis, syndromic management is
recommended and has been shown to be accurate and effective. With
syndromic management, immediate treatment is given for all major causes of
genital ulceration, based on local information about causes of ulcers and
their drug susceptibility.
Slide 15
Another problem frequently seen in women with HIV infection is abnormal
vaginal discharge. This can be caused by one or more vaginal infections,
including bacterial vaginosis, candidiasis, or trichomoniasis. The first
and most common type of vaginal infection, bacterial vaginosis or BV, is
not caused by a single type of bacteria, but by an overgrowth of different
pathogenic bacteria that alter the normal vaginal environment. BV has been
associated with an increased risk of pelvic inflammatory disease and, in
pregnant women, an increased risk of preterm labor and premature rupture
of membranes. More recent information has shown that BV may enhance HIV
transmission, both sexual transmission and mother-to-child transmission.
The second type of vaginal infection, candidiasis or yeast infection,
may increase in frequency with progressive HIV disease, as the immune
system becomes more suppressed. These infections are also common after
antibiotic treatment in both HIV-infected and HIV-uninfected individuals.
The third common type of vaginal infection is trichomoniasis, a protozoan
infection that is transmitted sexually. Syndromic management of abnormal
vaginal discharge, including treatment for these three types of
infections, is recommended and is effective for the treatment of vaginal
infections.
Slide 16
Another major cause of abnormal vaginal discharge is infection of the
cervix or cervicitis. The two most common causes of cervicitis are
gonorrhea and chlamydia, both of which are sexually transmitted.
Unfortunately, syndromic management for abnormal vaginal discharge is less
accurate in the diagnosis and management of cervicitis. If specific
testing for gonorrhea and chlamydia is not available, other information
should be used to make decisions about treatment, including personal risk
assessment, local information about how frequently these infections are
found, and other symptoms or signs, such as a cervical swab showing a
purulent discharge. Sex partners should also be treated if a diagnosis of
cervicitis is made.
Slide 17
Both gonorrhea and chlamydia are major causes of pelvic inflammatory
disease or PID, which is an upper genital tract infection involving the
endometrial cavity, fallopian tubes, ovaries, and the peritoneal cavity.
Most women with PID present complaining of lower abdominal pain. On
physical examination, the presence of lower abdominal tenderness, adnexal
tenderness, and cervical motion tenderness form the basis for clinical
diagnosis. The presence of other simple findings, such as fever and
abnormal discharge increase the accuracy of diagnosis. If available,
pregnancy testing should be performed, since ectopic pregnancy may present
with similar findings. In women with HIV infection, PID may be both more
common and more severe. Treatment with antibiotics to cover gonorrhea,
chlamydia, and other aerobic and anaerobic bacteria is indicated.
Hospitalization for intravenous therapy should be considered with severe
PID and in women who have symptomatic HIV.
Slide 18
Perhaps the most common gynecologic problem women with HIV have is
infection with human papillomavirus, leading to cervical dysplasia and
possibly cervical cancer. Each year nearly 400,000 new cases of cervical
cancer occur and at least 200,00 die of the disease. Almost 80% of
cervical cancer cases occur in women living in developing countries. An
important reason for the higher cervical cancer rates in developing
countries is the lack of effective screening programs designed to identify
precancerous lesions and treat them before they progress to invasive
cancer.
Slide 19
We now know that the cause of cervical cancer is infection with a
sexually transmitted virus called human papillomavirus or HPV. One or more
cancer causing types of HPV have been found in over 99% of cases. Of the
more than 100 types of HPV, however, only a small group, types 16, 18, 33
and a few others, have been shown to cause cervical cancer. The other HPV
types only produce a temporary infection. Women are generally infected
with HPV in their early teens, twenties or thirties when they first become
sexually active. In the US and Europe, HPV is the most common STI,
occurring at some point in up to 75% of sexually active women. In many
women, the interval from becoming infected with the papillomavirus and
developing cancer can be as long as 20 years.
Slide 20
Women with HIV have higher rates of HPV infection and longer
persistence of HPV, a characteristic that has been linked to greater
likelihood of progression to precancerous changes or cervical dysplasia.
Women with HIV are also more likely to have infection with multiple HPV
types and greater frequency of oncogenic or cancer-causing HPV types. Both
the likelihood of HPV infection and its persistence increase with lower
CD4 cell counts and higher viral loads.
Slide 21
When cervical dysplasia does develop in the HIV-infected woman, rates
of these precancerous changes are much greater than those seen in
HIV-negative women. Furthermore, the likelihood and the severity of these
changes increase with advancing HIV disease. Overall, there appears to be
a shortened time from initial HPV infection to development of cervical
dysplasia and cancer without adequate screening and treatment programs.
Slide 22
Precancerous changes caused by HPV in the woman with HIV infection
often involves a larger area of the cervix and is more likely to affect
other areas in the lower genital tract as well, such as the vulva, vagina,
and perianal region. There is also an increased likelihood of recurrence
after treatment for cervical dysplasia. In the absence of screening and
treatment, invasive cervical cancer may develop. For the woman with HIV
infection, cervical cancer often presents at more advanced stages and is
less likely to have a good response to standard treatment.
Slide 23
What can be done to prevent cervical cancer in limited-resource
settings? There is a possible role for visual inspection of the cervix
with acetic acid and treatment with cryotherapy, although this has not yet
been studied in women with HIV. When treatment of the cervix with
cryotherapy or with excision is performed, larger areas of the cervix may
need to be treated and more frequent and careful follow-up after treatment
is needed. Because the entire lower genital tract may be involved with
precancerous changes, it is important to carefully inspect the vulva,
vagina, and perianal region.
Slide 24
What is VIA? VIA or Visual Inspection With Acetic Acid is looking at
the cervix to detect abnormalities after applying a dilute solution of
acetic acid, which is the most common ingredient in household vinegar.
What does the acetic acid do to cells? If immature or precancerous cells
are present, the acetic acid will turn their cytoplasm cloudy. To the
human eye, this reaction looks white and is referred to as an "acetowhite"
change; the tissue itself is often referred to as white epithelium. Mature
squamous cells and glandular cells do not react this way.
Slide 25
Why is VIA a practical alternative for use in limited-resource
settings? First of all, it is safe, easy to perform, inexpensive and easy
to learn. Second, it can be performed by all types of healthcare workers
in almost any setting. Third, the skills needed are consistent with the
service delivery tasks performed by nurses and midwives in primary
healthcare settings. Most importantly, the results are available
immediately. Because of this, the potential exists for linking testing to
treatment at the same time. Finally, VIA can be performed in any clinic
setting. All that is needed are:
--an adequate light source for looking at the cervix and examining it
in detail --a vaginal speculum --an examining table permitting the
examiner to insert the speculum and view the cervix --dilute 3-5% acetic
acid or vinegar --vaginal swabs, and --new examination gloves or
high-level disinfected surgical gloves to protect the healthcare worker
Slide 26
Several well-designed and rigorous scientific studies have now been
completed which confirm VIA's usefulness as a screening tool in
limited-resource settings. Some of these studies found that VIA was more
sensitive than the Pap smear in detecting severe dysplasia or worse
lesions. A major finding from the study in Zimbabwe was that nonphysicians,
in this case nurse-midwives, quickly learned to perform VIA in a primary
healthcare setting and were able to correctly identify women with no
disease, those suitable for immediate treatment, and those requiring
referral for advanced disease. Based on these studies, VIA represents a
proven and simple alternative means of identifying women with precancerous
cervical lesions.
In conclusion, women with HIV infection have a number of reproductive
health needs and problems. Provision of appropriate family planning
counseling and services, with a focus on dual method use or dual
protection with condoms, is important to prevent unintended pregnancy, as
well as to prevent sexual transmission of HIV to uninfected partners.
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 women with
HIV.
