New Gynecological Care Guidelines for Women with HIV

		SUMMARY: All women should be routinely screened for HIV, and those found to be positive should undergo regular monitoring of their gynecological health, including tests for human papillomavirus (HPV) -- the cause of cervical cancer -- and other sexually transmitted diseases, according to guidelines issued last week by the American College of Obstetricians and Gynecologists (ACOG). Women should use condoms to prevent HIV transmission, but adding a second birth control method is more effective for preventing pregnancy. HIV positive women who wish to become pregnant should receive prompt prenatal care so they can receive appropriate antiretroviral therapy (ART) to ensure their own health and prevent mother-to-child transmission of the virus.

Below is a press release issued by ACOG summarizing the new recommendations.

New Focus on Care for HIV+ Women as More
Live Longer with the Disease

Washington, DC -- November 22, 2010 -- As the number of women in the US living with HIV/AIDS increases, ob-gyns will need to address their unique contraception, preconception and prenatal care, and general gynecologic requirements. In guidelines issued today, the American College of Obstetricians and Gynecologists (The College) emphasizes that ob-gyns will play a greater role in providing routine gynecologic care to HIV-infected women as these women live longer, healthier lives.

Approximately 27% of all HIV/AIDS cases in the US today are among women, up from 7% in 1985. Black and Hispanic women are disproportionately affected, accounting for 80% of all HIV+ women today. Heterosexual contact accounts for 72% of HIV transmission among women in the US.

"Most of the women living with HIV today in the US are in their prime reproductive years," said Hal C. Lawrence, MD, vice president of practice activities for The College. "As the number of women with HIV diagnoses increases, ob-gyns will -- if they haven't already -- begin to see more patients who are HIV-positive. These guidelines cover the recommended health screenings, counseling, and routine gynecologic care for these women."

Gynecologic Care

The College recommends routine HIV screening for all women ages 19-64, and targeted screening for women who have risk factors that fall outside of this age range, for example, sexually active or intravenous drug-using adolescents younger than 19 years. Both the Centers for Disease Control and Prevention (CDC) and The College recommend that all reproductive-age women be screened for HIV at least once in their lifetime, but there is no consensus on how often they should be retested. Ob-gyns should review their patients' risk factors annually to determine the need for retesting. Some women should be offered repeat HIV screening at least annually, including those who: are injection drug users; have sex partners who are injection drug users or who are HIV+; exchange sex for drugs or money; have been diagnosed with an STD in the past year; or have had more than one sex partner since their last HIV test.

The College recommends that HIV+ women be treated aggressively for other sexually transmitted diseases (STDs). "Having another STD in addition to HIV may increase the risk of transmitting HIV to others," said Roxanne M. Jamshidi, MD, who assisted in the development of the new guidelines. This is because having other STDs increases shedding of the HIV virus. The CDC recommends annual screening -- or more frequently, if necessary -- for curable STDs such as syphilis, gonorrhea, and chlamydia among sexually active women with HIV.

In general, women with HIV have a higher rate of bacterial vaginosis and yeast infections than other women. "These infections appear to be more common and more persistent among women with HIV who are immunosuppressed," said Dr. Jamshidi. The treatment for yeast infections for HIV+ women who have compromised immune systems may require slightly longer treatment, and those women with recurrent yeast infections may need long-term medication to prevent future yeast infections.

The prevalence and persistence of human papillomavirus (HPV) are more common among women with HIV, and both increase with worsening immunosuppression. Thus, The College recommends that HIV+ women have cervical screening twice in the first year after being diagnosed and get screened annually thereafter to avoid developing cervical cancer. Although women with HIV who get the recommended screening don't have a higher rate of cervical cancer than other women, they do, in general, have higher rates of vaginal, vulvar, and perianal precancer. They are also at increased risk for anal cancer compared with the general population. Close scrutiny should be paid to these areas in HIV+ woman, say the recommendations.

The Gardasil HPV vaccine has been proven safe in HIV+ children, but whether it's effective in preventing HPV in women or girls with HIV is unknown. The CDC's recommendations for HPV vaccination of children and adolescents is the same, regardless of HIV status.

Contraception

Dual contraception (using two different types of contraception at the same time) is the optimal way for women with HIV to reduce the risk of transmitting HIV and other STDs as well as to prevent pregnancy. Although condoms are the only effective method of avoiding STDs during intercourse, they are not the most effective way to prevent pregnancy. "Women with HIV will need to use condoms each time they have intercourse, but they also need to use additional contraception to prevent unintended pregnancy," said Dr. Jamshidi. Overall, hormonal contraception is safe for HIV+ women, but combined (estrogen + progestin) oral contraceptives are generally not recommended for women taking certain antiretroviral medications because of the potential of each to lessen the effectiveness of the other medication. Intrauterine devices (IUDs) are often a good contraceptive option for HIV+ women.

Preconception Care and Pregnancy

The introduction of antiretroviral medications over the last decade has significantly decreased the rate of mother-to-child HIV transmission in the US to less than 1%. As more HIV+ women choose to have children, ob-gyns need to be prepared for detailed preconception discussions with their patients on how to avoid transmission of the virus to the baby, their partner, or to themselves from an HIV+ partner. Transmitting HIV to the baby can be greatly reduced by taking antiretrovirals during pregnancy to keep the virus at undetectable levels, by avoiding breastfeeding, and by giving newborns preventive antiretrovirals for several weeks after birth.

"Women with HIV can have healthy pregnancies and healthy babies, but it takes careful planning," said Dr. Jamshidi. Achieving pregnancy without transmitting the virus to a partner is best accomplished through artificial insemination instead of unprotected intercourse. Donor insemination from an HIV-negative male is the safest option for women who are HIV- but whose partners are HIV+, according to The College.

Menopause

Increasing numbers of women with HIV are going through menopause, according to The College. Studies suggest that the average age of menopause among HIV+ women is about three to four years younger than other women. "This may be due to smoking, drug abuse, and low body weight which are common among women with HIV," said Dr. Jamshidi. Low bone mass is more prevalent among HIV+ women nearing menopause, but data to date are lacking on the treatment of osteoporosis in this subset of women. Increasing physical activity, stopping smoking, and taking calcium and vitamin D supplements, however, are standard suggestions to prevent further bone loss.

Practice Bulletin #117, "Gynecologic Care for Women with Human Immunodeficiency Virus," is published in the December 2010 issue of Obstetrics & Gynecology.

About ACOG

The American College of Obstetricians and Gynecologists is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 55,000 members, The American College of Obstetricians and Gynecologists strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women's health care.

12/3/10

Reference
American College of Obstetricians and Gynecologists. Practice Bulletin No. 117: Gynecologic care for women with human immunodeficiency virus. Obstetrics & Gynecology 116(6): 1492-1509. December 2010.

Other Source
American College of Obstetricians and Gynecologists. New Focus on Care for HIV+ Women as More Live Longer with the Disease. Press release. November 22, 2010.