Module 4Module 4

HIV Infection in WomenHIV Infection in Women

HIV Infection in WomenHIV Infection in Women

• Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware

• Staff of the Pennsylvania/Mid-Atlantic AIDS Education & Training Center, Delaware Local Performance Site - P. Lincoln, N. Bennett, M.A. Bartkowski

• Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware

• Staff of the Pennsylvania/Mid-Atlantic AIDS Education & Training Center, Delaware Local Performance Site - P. Lincoln, N. Bennett, M.A. Bartkowski

Demographics of HIV in WomenDemographics of HIV in Women

• Fastest growing group in the United States • 4th leading cause of death aged 25 to 44 in

the United States• Disproportionately affects African

Americans & Hispanics living on the eastern seaboard

CDC-2000

• Fastest growing group in the United States • 4th leading cause of death aged 25 to 44 in

the United States• Disproportionately affects African

Americans & Hispanics living on the eastern seaboard

CDC-2000

Statistics of HIV in WomenStatistics of HIV in Women

• Cumulative Statistics as of December 2000 in the United States 74,997 African American 28, 151 White 25,643 Hispanic 1,133 Other

• Total 130, 104 CDC

2000

• Cumulative Statistics as of December 2000 in the United States 74,997 African American 28, 151 White 25,643 Hispanic 1,133 Other

• Total 130, 104 CDC

2000

HIV Transmission Risk Behaviors for WomenHIV Transmission Risk Behaviors for Women

• Heterosexual - 62% African American - 63% White - 18% Hispanic - 18% Other - 1% primary risk behavior for all age groups of women

• IVDU - 35%• Other - 3%

CDC 2000

• Heterosexual - 62% African American - 63% White - 18% Hispanic - 18% Other - 1% primary risk behavior for all age groups of women

• IVDU - 35%• Other - 3%

CDC 2000

Female CondomFemale Condom

• “Reality” - only brand currently marketed in the US

• Made of polyurethane, sheath closed at one end with flexible rings at both ends

Anderson, J. 2001

• “Reality” - only brand currently marketed in the US

• Made of polyurethane, sheath closed at one end with flexible rings at both ends

Anderson, J. 2001

MicrobicidesMicrobicides

• Strategy enabling women to have control over safer sex/prevention of HIV

• Nonoxynol-9 increases risk of HIV infection

• Clinical trials of topical microbicides are being conducted

Anderson, J. 2001

• Strategy enabling women to have control over safer sex/prevention of HIV

• Nonoxynol-9 increases risk of HIV infection

• Clinical trials of topical microbicides are being conducted

Anderson, J. 2001

Gender Bias TransmissionGender Bias Transmission

• More efficient from man to woman than woman to man

• Related to number of infectious particles in body fluid

• Related to volume of fluids exchanged• Related to surface area coming in contact with

infected body fluid

HRSA:BPHC & AETC

• More efficient from man to woman than woman to man

• Related to number of infectious particles in body fluid

• Related to volume of fluids exchanged• Related to surface area coming in contact with

infected body fluid

HRSA:BPHC & AETC

Risk Factors for Male to Female HIV Transmission

Risk Factors for Male to Female HIV Transmission

• Anal Intercourse

• Lack of male circumcision

• Genital ulcers (syphilis, herpes simplex, chancroid)

• Sexually Transmitted Diseases

• Multiple sexual partners

• Anal Intercourse

• Lack of male circumcision

• Genital ulcers (syphilis, herpes simplex, chancroid)

• Sexually Transmitted Diseases

• Multiple sexual partners

Special ConsiderationSpecial Consideration

• Early Adolescent immaturity of the female genital track

increases risk of transmission

• Women over 50 years of age atrophic vaginitis caused by decreased

lubrication older females are generally not perceived to

be at risk

• Early Adolescent immaturity of the female genital track

increases risk of transmission

• Women over 50 years of age atrophic vaginitis caused by decreased

lubrication older females are generally not perceived to

be at risk

Natural History of HIV Disease in Women

Natural History of HIV Disease in Women

• Same as in men except for GYN symptoms and disease conditions

• 1993 CDC added invasive cervical cancer as an AIDS defining condition

• Women are often diagnosed late• Women may have barriers to care

HRSA:BPHC & AETC

• Same as in men except for GYN symptoms and disease conditions

• 1993 CDC added invasive cervical cancer as an AIDS defining condition

• Women are often diagnosed late• Women may have barriers to care

HRSA:BPHC & AETC

Challenges in Caring for Women with HIV

Challenges in Caring for Women with HIV

• Statistically economically poorer than men

• More likely to be single parents lack of child care lack of support

• More likely to be uninsured HRSA:BPHC & AETC

• Statistically economically poorer than men

• More likely to be single parents lack of child care lack of support

• More likely to be uninsured HRSA:BPHC & AETC

Signs and Symptoms of HIV in Women

Signs and Symptoms of HIV in Women

• Acute Seroconversion - (No distinct gender differences however many of these s&s often go under addressed) fever swollen glands

Bartlett, J. 1999

• Acute Seroconversion - (No distinct gender differences however many of these s&s often go under addressed) fever swollen glands

Bartlett, J. 1999

Signs and Symptoms of HIV in Women cont’

Signs and Symptoms of HIV in Women cont’

Rash - macular or maculopapular, usually nonpururitic. Truncal / facial distribution can involve arms and legs. Often appears several days past onset of fever.

Fatigue Mono-spot test is negative

Bartlett, J. 1999

Rash - macular or maculopapular, usually nonpururitic. Truncal / facial distribution can involve arms and legs. Often appears several days past onset of fever.

Fatigue Mono-spot test is negative

Bartlett, J. 1999

HIV-Related Gynecological Conditions

HIV-Related Gynecological Conditions

• Vaginal candidiasis

• Human Papilloma Virus

• Genital Ulcers

• Pelvic Inflammatory Disease

• Cervical Dysplasia/Neoplasia

• Menstrual Disturbances HRSA:BPHC & AETC

• Vaginal candidiasis

• Human Papilloma Virus

• Genital Ulcers

• Pelvic Inflammatory Disease

• Cervical Dysplasia/Neoplasia

• Menstrual Disturbances HRSA:BPHC & AETC

Diagnostic StudiesDiagnostic Studies

• Pap smear two studies the first year of diagnosis annually if normal recommended every 6 months if HIV is

symptomatic

• Colposcopy

USPHS/IDSA 2001

• Pap smear two studies the first year of diagnosis annually if normal recommended every 6 months if HIV is

symptomatic

• Colposcopy

USPHS/IDSA 2001

Prenatal & Family Planning HIV Screening

Prenatal & Family Planning HIV Screening

• DHHS guidelines suggest universal HIV testing with patient notification as a routine component of prenatal care

• Pre and post test counseling & informed consent - laws vary by state

USPHS/IDSA 2001

• DHHS guidelines suggest universal HIV testing with patient notification as a routine component of prenatal care

• Pre and post test counseling & informed consent - laws vary by state

USPHS/IDSA 2001

PregnancyPregnancy

• Does not appear to accelerate HIV infection

• Does not appear to accelerate HIV infection

Perinatal HIV Transmission May Occur

Perinatal HIV Transmission May Occur

• Antepartum during pregnancy

• Intrapartum during labor during delivery

• Postpartum-through breast feeding HRSA:BPHC & AETC

• Antepartum during pregnancy

• Intrapartum during labor during delivery

• Postpartum-through breast feeding HRSA:BPHC & AETC

Reducing Perinatal TransmissionReducing Perinatal Transmission

• ACTG 076 women given AZT after first trimester AZT administered intravenously during labor newborn receives AZT for 6 weeks transmission reduced by 67.5%

• Combination therapy has reduced the rate even further

HRSA:BPHC & AETC

• ACTG 076 women given AZT after first trimester AZT administered intravenously during labor newborn receives AZT for 6 weeks transmission reduced by 67.5%

• Combination therapy has reduced the rate even further

HRSA:BPHC & AETC

Antepartum/Intrapartum Management Considerations

Antepartum/Intrapartum Management Considerations

• Avoid amniocentesis

• Avoid premature rupture of membranes

• Avoid fetal scalp monitoring• Delay episiotomy

HRSA:BPHC & AETC

• Avoid amniocentesis

• Avoid premature rupture of membranes

• Avoid fetal scalp monitoring• Delay episiotomy

HRSA:BPHC & AETC

HIV Medications to avoid during Pregnancy

HIV Medications to avoid during Pregnancy

• Efavirenz - associated with anencephaly, anopthalmia Neural tube defects in primates

• Indinavir - Potential for nephrolithiasis and neonatal hyperbilirubinemia

DeLorenzo, L. 2001

• Efavirenz - associated with anencephaly, anopthalmia Neural tube defects in primates

• Indinavir - Potential for nephrolithiasis and neonatal hyperbilirubinemia

DeLorenzo, L. 2001

HIV Medications to avoid during Pregnancy, cont’

HIV Medications to avoid during Pregnancy, cont’

• Didanosine/Stavudine - combination associated with fatal lactic acidosis in pregnancy

• Stavudine/Retrovir -combination is antagonistic, decreasing efficacy of therapy

DeLorenzo, L. 2001

• Didanosine/Stavudine - combination associated with fatal lactic acidosis in pregnancy

• Stavudine/Retrovir -combination is antagonistic, decreasing efficacy of therapy

DeLorenzo, L. 2001

Antiretroviral Pregnancy RegistryAntiretroviral Pregnancy Registry

• Collaborative effort between the CDC, NIH and pharmaceutical companies to monitor for birth defects in infants exposed to antiretroviral agents

• antiretroviral exposure during pregnancy should be reported to the registry at 1-800-258-4263

Anderson, J. 2001

• Collaborative effort between the CDC, NIH and pharmaceutical companies to monitor for birth defects in infants exposed to antiretroviral agents

• antiretroviral exposure during pregnancy should be reported to the registry at 1-800-258-4263

Anderson, J. 2001

Current Prevention Message-Is it Reality ?

Current Prevention Message-Is it Reality ?

• Abstinence

• Monogamy

• Reduce number of partners

• Ask partner about history of infection

• Enforce use of condoms

Colmorgen, G. 1999

• Abstinence

• Monogamy

• Reduce number of partners

• Ask partner about history of infection

• Enforce use of condoms

Colmorgen, G. 1999

Prepared by Christopher W. James, Pharm.D.Clinical Pharmacist, HIV Community Program5/6/02

FDA Pregnancy Categories for Antiretroviral Agents and Associated Medications

Category A

Controlled StudiesShow No Risk

Category B

No Evidence of Risk inHumans

Category C

Risk Cannot Be Ruled Out

Category D

Positive Evidenceof Risk

Category X

Contraindicated InPregnancy

Amphotericin BAzithromycinClindamycin

CyproheptadineDidanosine

Growth HormoneMetronidazole

NelfinavirNystatinRifabutinRitonavir

SaquinavirTenofovir

AbacavirAcyclovir

AlbendazoleAmprenavir*†AtovaquoneCidofovir

CiprofloxacinClarithromycinClotrimazole

DapsoneDelaviridineDronabinolEfavirenz*

ErythropoietinEthambutolFluconazoleFlucytosineFomivirsenFoscarnet

GanciclovirIndinavir

InterferonsIsoniazid

ItraconazoleLamivudine

Lopinavir/RitonavirNevirapine

PentamidinePrimaquine

PyrazinamidePyrimethamine

StavudineSulfadiazine

TrimethoprimTrimethoprim/

SulfamethoxazoleZalcitabineZidovudine

HydroxyureaMegestrol Acetate

OxandroloneRibavirin

TestosteroneThalidomide

* Contraindicated in pregnancy† Oral solution only; contains significant amount of propylene glycol

ReferencesReferences

• Anderson, J. (Ed.) (2001). A guide to the clinical care of women with HIV. Rockville, MD: HIV/AIDS Bureau, Health Resources and Services Administration. [Available on-line: http://www.hab.hrsa.gov/publications.html].

• Bartlett, J. & Gallant, J. (2001). 2001-2002 Medical Management of HIV Infection. [Available on-line: http;//hopkins-aids.edu

• Anderson, J. (Ed.) (2001). A guide to the clinical care of women with HIV. Rockville, MD: HIV/AIDS Bureau, Health Resources and Services Administration. [Available on-line: http://www.hab.hrsa.gov/publications.html].

• Bartlett, J. & Gallant, J. (2001). 2001-2002 Medical Management of HIV Infection. [Available on-line: http;//hopkins-aids.edu

References, cont’References, cont’

• Center for Disease Control and Prevention. (2002,February). Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. [Available on-line: http://www.hivatis.org.]

• Center for Disease Control and Prevention. (2002,February). Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. [Available on-line: http://www.hivatis.org.]

References, cont’References, cont’

• DeLorenzo, L. (2001). Clinical Nursing Series. Nursing Care of the HIV-Infected Patient. Fourth Edition. Western Schools Press.

• DeLorenzo, L. (2001). Clinical Nursing Series. Nursing Care of the HIV-Infected Patient. Fourth Edition. Western Schools Press.