Clinical Guide > HIV Treatment > Women's Life Cycle

# Health Care of HIV-Infected Women Through the Life Cycle

*Author:* Susan  Richardson, MN, MPH, FNP-BCJanuary 2011

### Chapter Contents

      - Background 
      - Epidemiology and Factors Affecting HIV Transmission
      - Psychosocial/Emotional Factors Unique to Women
      - ART Issues Particular to Women
      - Baseline Reproductive History
      - Elements of Gynecological Care
      - Contraception
      - Preconception Counseling
      - Menopause
      - ReferencesTable 1: Special Considerations for Use of Antiretrovirals with WomenTable 2: Routine Gynecologic Screening and Counseling for WomenTable 3: Advantages and Disadvantages of Various ContraceptivesBackground 
Women with HIV infection have the same reproductive and life cycle health needs and concerns as women without HIV infection. However, for women with HIV infection, certain gynecologic problems may be more common or more frequent. In addition, issues regarding antiretroviral therapy (ART), contraception, and preconception counseling require special attention. This chapter addresses some of the unique health care needs of HIV-infected women across the lifespan, from menarche through postmenopause, and describes the essential elements of care. For further information, see chapters *Reducing Maternal-Infant HIV Transmission*, *Care of HIV-Infected Pregnant Women*, and *Antiretroviral Medications and Hormonal Contraceptive Agents*.
Epidemiology and Factors Affecting HIV Transmission
Heterosexual transmission of HIV is more efficient from man to woman than from woman to man. Transmission can occur through intact vaginal tissue; no damage to the vaginal lining is required. Women have specific risks of HIV acquisition at different phases of the lifespan: 
- Young adolescents have immature genital tracts and increased cervical ectopy (increased vulnerability to HIV and other sexually transmitted infections [STIs])
- Women of reproductive age may desire pregnancy and childbearing (potentially increasing risky sexual behaviors)
- Married or partnered women may be monogamous with male partners who have risk factors for HIV infection (women may lack awareness of partner's risk behaviors)
- Postmenopausal or posthysterectomy women may have vaginal atrophy (decreasing the anatomic barrier to HIV), or may have no fear of pregnancy or have a perception that they are at low risk of infection (increasing risky sexual behaviors)
- Additionally, woman-to-woman transmission may occur if risk factors are present
Psychosocial/Emotional Factors Unique to Women
Heterosexual women frequently are faced with unequal power and socioeconomic relationships with their male partners. These women may be more likely to exchange sex for money, less likely to successfully negotiate protected sex, and less likely to leave a relationship they perceive as risky. Women may be more vulnerable to domestic violence and sexual coercion, especially those with histories of childhood sexual abuse. Also, women may inherit social roles and responsibilities as caretakers for extended family members and often for friends.
ART Issues Particular to Women
In general, women on ART have virologic and immunologic responses comparable to those of men; however, several studies have shown that women discontinue ART more frequently than men. Women have higher rates of adverse effects from a number of antiretroviral (ARV) medications, in part because serum levels of at least some ARVs are higher in women. Pregnancy may require changes in ART, either because of pharmacokinetic changes or because of toxicity. See below.
Table 1: Special Considerations for Use of Antiretrovirals with WomenARV Issues for WomenConsiderations ARV adverse effects Some ARV adverse effects may be more severe in women: - Anemia (zidovudine)
- Lactic acidosis (particularly with stavudine + didanosine)
- Neuropathy (stavudine, didanosine)
- Hepatotoxicity (nevirapine)
- Severe rash (nonnucleoside reverse transcriptase inhibitors [NNRTIs], darunavir, tipranavir)
- Abacavir hypersensitivity
- Lipoaccumulation: central fat accumulation in breasts, abdomen; lipoatrophy: face
- Bone loss, especially after menopause
 Pregnancy  Teratogenicity: - Efavirenz is associated with neural tube defects in women with exposure during the first-trimester; should be avoided in pregnant women during the first trimester, and in women who may become pregnant
 Pharmacokinetic (PK) changes: - Serum levels of some ARVs may be decreased during pregnancy (e.g., unboosted protease inhibitors [PIs], lopinavir/ritonavir, ritonavir)
- Some ARVs should be avoided and certain ARVs may require dosage adjustment in the third trimester
- PK studies in pregnancy are not available for some ARVs
 See chapter *Reducing Maternal-Infant HIV Transmission* Contraception There are significant interactions between some hormonal contraceptive agents and certain ARVs; see "Contraception," belowBaseline Reproductive History
Taking a careful reproductive history should be a part of routine primary care for any woman. Important information to gather includes the following:
- Age of menarche
- Menstrual history: last menstrual period (LMP), amenorrhea, menstrual irregularity, uterine fibroids, endometriosis
- Obstetrical history: G-P-A-L    - G (gravida, or number of pregnancies), P (parity, or number of births), A (abortion; number of miscarriages or terminations), L (number of living children)
  - Pregnancy complications and outcomes: full-term, premature births, mode of deliveries
  - Use of ART during pregnancy
  - HIV status of children
- Sexual activity: vaginal, oral, anal; condom use; number of partners; sex of partners; HIV status of partners
- Contraception, past and current
- Date of last Papanicolau (Pap) test and results; history of abnormal Pap test results
- Gynecologic procedures: colposcopy/biopsy, loop electrosurgical excision procedure (LEEP), cervical surgery, tubal ligation, partial or total hysterectomy; and indication for these
- STIs, bacterial vaginosis, vulvovaginal candidiasis, herpes, warts; especially recurrence
- Current symptoms: vaginal discharge, vulvar/vaginal/anal pain, dysuria, dyspareunia (pain with intercourse), lesions, intermenstrual bleeding, postcoital bleeding
Elements of Gynecological Care
Women with HIV infection should receive routine screening for gynecologic cancers and infections. Cervical dysplasia and cancer continue to be widespread, especially among women with low CD4 counts, and it is not clear that initiation of suppressive ART improves clinical outcomes of women with dysplasia (see chapter *Cervical Dysplasia*). Other common gynecological problems include recurrent yeast vaginitis, pelvic inflammatory disease; vaginal, vulvar, and anal warts, which are potentially oncogenic; and perineal/perianal herpes that may become severe and recurrent.

Women also should be evaluated for risk of breast cancer, for contraceptive needs, and for preconception counseling
Table 2: Routine Gynecologic Screening and Counseling for WomenMedical Service  Comments  Cervical and anal cancer screening- Screen all HIV-infected women for cervical cancer, to age 65 (cervical Pap test)    - At initial visit, at 6 months, then annually unless abnormal
- Consider anal cancer screening (anal Pap test) for all HIV-Infected women
- If cervical or anal Pap screen shows atypical squamous cells of undetermined significance (ASCUS) or dysplasia of any grade, seek colposcopy    - See chapters  Cervical Dysplasia  and  Anal Dysplasia
- Perform pelvic examination    - Include vulvar and anal examination at each visit
  - Assess for potentially dysplastic lesions
STI screening- Gonorrhea, chlamydia, syphilis at least annually, and more frequently depending on risk factors
Breast cancer screening- Mammography    - Mammogram every 1-2 years recommended for women 50-69 years of age
  - Consider annual mammogram for women 40-50 years of age
  - Consider starting earlier if risk factors are present
  - For women ≥70 years of age, decisions about whether to continue screening should take into account the woman's life expectancy and clinical status
- Clinical breast examination    - Annually      - Breast self-examination (BSE) monthly (assess technique)
Contraceptive counseling- Assess life dynamics and need for contraception at every visit
- Stop only after hysterectomy or sterilization
- See " Contraception ," below
Preconception counseling- Annually or more often for all women of reproductive age    - Ask about pregnancy desires at every visit
  - See " Preconception Counseling ," below
Contraception
Many contraceptive choices are available for HIV-infected women; some considerations are presented in the table below. For more information about interactions between ARVs and hormonal agents, see chapter *Antiretroviral Medications and Hormonal Contraceptive Agents*. Depending on the woman's (and her partner's) risk factors, consistent condom use should be emphasized, with or without other methods of contraception, to prevent the transmission of HIV and the acquisition or transmission of other STIs.
Table 3: Advantages and Disadvantages of Various Contraceptives Contraceptive Type AdvantagesDisadvantages* See chapter *Antiretroviral Medications and Hormonal Contraceptive Agents* and U.S. Department of Health and Human Services *Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents*. January 10, 2011.**Barrier Methods** Male and female condom- Only method that protects against transmission of HIV and STIs
-  Requires partner cooperation and correct technique
-  High failure rate when used incorrectly
 Diaphragm and cervical cap- Requires correct technique
- High failure rate when used incorrectly
**Hormonal Methods***- Do not prevent STI or HIV transmission
 Oral- Very effective
- Lighter menstrual flow
- May have significant drug-drug interactions with PIs and NNRTIs that may affect the efficacy and toxicity of estradiol or norethindrone, and of certain PIs*
- Consider alternative methods for women taking PIs or NNRTIs
 Injectable depot medroxyprogesterone acetate (DMPA, Depo-Provera)- Effective contraception for 3 months
- May cause amenorrhea
- Concern about osteoporosis with long-term use
- Irregular bleeding, especially initially
- Weight gain
 Transdermal (patch)- Effective
- Lighter menstrual flow
- No studies to document pharmacokinetic interactions, but of possible significance
 Vaginal ring- Effective
- Lighter menstrual flow
- No studies to document pharmacokinetic interactions, but of possible significance
 Intrauterine devices (IUDs)- Effective for long-term use
- No evidence of increased HIV viral shedding
- Progestin-releasing IUD may cause lighter menstrual flow
- Possible blood loss with Copper T IUD
- Insertion of IUD not recommended for women with advanced immunosuppression
 Etonogestrel implant- Effective
- Amenorrhea
- No studies to document pharmacokinetic interactions, but of possible significance
 Emergency contraception:- Levonorgestrel
- Copper T IUD
- Effective
- Appropriate for women who present 4-5 days after intercourse
- Efavirenz lowers levonorgestrel levels; use alternative method
- Pharmacokinetic interactions with other ARVs have not been studied, but are of possible significance
- Heavy blood loss
**Surgical Methods**Bilateral tubal ligation (female)- Effective; permanent
- Does not prevent transmission of HIV or other STIs
- No future fertility (usually not reversible)
Vasectomy (male)- Effective; permanent 
- Does not prevent transmission of HIV or other STIs
- No future fertility (usually not reversible)
**Spermicides**Spermicides- Not currently recommended
- Nonoxynol-9 causes mucosal damage to vagina
- Do not prevent transmission of HIV or other STIs
Preconception Counseling
As discussed above, every visit with an HIV-infected woman in her reproductive years presents an opportunity to discuss pregnancy desires and options, including gathering information about her partner. It is important to assess the couple's sexual history, sexual decision making, and control of reproductive options. When a woman desires pregnancy, it is important to discuss the following, with the goals of educating her and decreasing risk of HIV transmission to an HIV-uninfected partner and to the fetus. Ideally, the partner will take part in the discussion. 
- Options for conception that decrease risk of HIV transmission to an HIV-uninfected partner
- Recommendations for ART before and during pregnancy and delivery
- Mode of delivery
- Treatment of an infant, both HIV exposed and HIV infected
- Risk of the infant being infected with HIV
- Care of an HIV-infected child
- Discouragement of breast-feeding
- Disclosure of the child's HIV status
- Guardianship of a child if one or both parents were to become ill or die

Any history of infertility or low fertility in either the patient or her partner should be evaluated and options for having children should be discussed, including current information on gamete donation, other assisted reproductive techniques, and adoption.

If the heterosexual couple is serodiscordant, techniques to minimize the risk of transmission to the uninfected partner should be discussed. These same techniques should be explained to couples when both partners are HIV infected, if there is a risk of transmitting different HIV "strains." Some of these techniques include the following: 
- Treatment of STIs
- Maximal suppression of the HIV viral load with ART
- Self-insemination of ejaculate using a syringe
- Estimating the time of ovulation; limiting intercourse to this time
- Pre- and/or post-exposure prophylaxis with ART by an uninfected partner
- Sperm washing
- In vitro fertilization

If the HIV-infected woman elects to initiate ART, an appropriate regimen should be started before pregnancy, avoiding agents with increased risk of teratogenicity (e.g., efavirenz), hepatotoxicity (e.g., nevirapine, in women with CD4 counts of >400 cells/µL), or metabolic complications such as lactic acidosis (e.g., didanosine and stavudine). See chapter *Reducing Maternal-Infant HIV Transmission* and the U.S. Department of Health and Human Services *Perinatal HIV Guidelines* (see "References," below). It should be noted that most fetal organogenesis occurs in the early weeks of pregnancy, before most women know that they are pregnant. Thus, any medication with potential teratogenicity or fetal toxicity, whether an ARV or another drug, should be avoided for use by women who are intending to become pregnant or have the potential for pregnancy. Certain medications (e.g., ribavirin)					should be avoided by male partners of women who may become pregnant.

Folate supplementation to reduce the risk of neural tube defects in the developing fetus should be started at least 1 month before conception, if possible, because the neural tube forms in the early weeks of pregnancy (see chapter *Care of HIV-Infected Pregnant Women*).
Menopause
There is evidence that HIV-infected women may be more likely to undergo premature physiologic menopause. Menopausal women are more at risk of premature bone loss, osteopenia, and osteoporosis; this risk may be increased by HIV infection. If indicated, bone density screening (DEXA) should be considered.

Hormone replacement therapy (HRT), especially of long duration, has been associated with an increased risk of breast cancer and cardiovascular and thromboembolic events, and its routine use is not currently recommended. HRT may be considered for women who experience severe vasomotor symptoms and vaginal dryness, but should be used only for a limited period of time and at the lowest effective dosage.
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- U.S. Department of Health and Human Services.  Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents . January 10, 2011.
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