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Number 117, December 2010
(Reaffirmed 2012)


Committee on Practice Bulletins—Gynecology This Practice Bulletin was developed by the Committee on Practice Bulletins—Gynecology with the assistance of Roxanne Jamshidi, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
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Gynecologic Care for Women With Human Immunodeficiency Virus

The increased use of screening tests has led to the identification of large numbers of women with human immunodeficiency virus (HIV). Consequently, there is an increased role for obstetrician–gynecologists in caring for infected women. Women infected with HIV are living longer, healthier lives and, therefore, the need for routine gynecologic care has increased. The purpose of this document is to educate clinicians about routine HIV screening practices as well as basic women's health screening and care, family planning, and preconception care for women who are infected with HIV.

Background

Basic Epidemiology and Prevalence

In the United States, women account for a growingproportion of patients with human immunodeficiencyvirus (HIV) and acquired immunodeficiency syndrome(AIDS) (from 7% in 1985 to 27% in 2007) (1). Heterosexual contact is responsible for 72% of HIV transmission among women in the United States, and women of color are disproportionately affected, accounting for 80% of HIV-infected women (1, 2). In most women with HIV, the infection is diagnosed during their reproductive years (1).

Antiretroviral Therapy for Nonpregnant HIV-infected Women

Treatment of HIV and AIDS should be provided by a health care practitioner with expertise in HIV. Such expertise has been shown to be a factor that prolongs the life of HIV-infected individuals (3, 4). A team approach is optimal to address both the medical and social complexity of HIV infection. In addition to obtaining a comprehensive medical history, including a gynecologic history and an HIV-related history, a detailed social history also should be obtained. Women with HIV often have life circumstances, such as alcohol or drug addiction, psychiatric illness, and domestic violence, that requirespecial attention (5). Appropriate sensitivity is needed to address these life circumstances and to treat HIV.

Box 1. Conditions Defining Acquired Immunodeficiency Syndrome

  • Candidiasis (bronchi, trachea, lungs, or esophagus)
  • Cervical cancer (invasive)
  • Coccidioidomycosis, cryptococcosis, and cryptosporidiosis
  • Cytomegalovirus disease
  • Encephalopathy (human immunodeficiency virus-related)
  • Herpes simplex (severe infection)
  • Histoplasmosis
  • Isosporiasis
  • Kaposi sarcoma
  • Lymphoma (certain types)
  • Mycobacterium avium complex
  • Pneumocystis jiroveci pneumonia
  • Pneumonia (recurrent)
  • Progressive multifocal leukoencephalopathy
  • Salmonella septicemia (recurrent)
  • Toxoplasmosis of the brain
  • Tuberculosis
  • Wasting syndrome

Data from 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep 1992;41(RR-17):1–19.

In nonpregnant adults, initiation of antiretroviral therapy is recommended for patients with a history of an AIDS-defining illness (Box 1) or a CD4 T-cell (or CD4) count of less than 500 cells per cubic millimeter. For patients with CD4 counts of 500 cells per cubic millimeter or greater, antiretroviral therapy may be offered (6). Antiretroviral medications select for resistant mutations when used as monotherapy; therefore, combinations of three or more drugs, often called highly active antiretroviral therapy (HAART), are used and strict adherence to the dose regimens is critical. There are currently more than 20 U.S. Food and Drug Administration (FDA)-approved antiretroviral agents from six medication classes that can be used to formulate combination regimens. Although long-term experience with antiretroviral agents is still limited, certain drugs merit special consideration in the treatment of women. Efavirenz is the preferred nonnucleoside reverse transcriptase inhibitor for the patients naïve to antiretroviral therapy, but it also is considered a possible teratogen because of data showing an increased risk of central nervous system defects in primates and a small number of case reports of neural tube defects in humans (FDA pregnancy category D) (7). Women offered efavirenz should be made aware of the potential teratogenic effects of this drug when used during pregnancy and that it is important to use effective and consistent contraception. The nonnucleoside reverse transcriptase inhibitor nevirapine is associated with an increased risk of symptomatic liver toxicity that can be severe and life-threatening. This risk is greater in women than men and is highest among those initiating nevirapine therapy with CD4 counts of greater than 250 cells per cubic millimeter (6). Therefore, nevirapine should not be used as a component of combination therapy in this setting unless the benefits clearly outweigh the risks. Liver toxicity has not been seen in women undergoing single-dose nevirapine therapy during labor for prevention of perinatal transmission (6).

Clinical Considerations and Recommendations

  • Who should be screened for HIV infection and what tests are available for screening?

Human immunodeficiency virus testing is an important and effective HIV prevention strategy. Therefore, the American College of Obstetricians and Gynecologists (the College) recommends routine HIV screening of women aged 19–64 years and targeted screening for women with risk factors outside of that age range; for example, sexually active or intravenous drug using individuals younger than 19 years (8). Although the Centers for Disease Control and Prevention (CDC) and the College both recommend that reproductive-aged women be tested at least once in their lifetime, there is no consensus regarding how often women should be retested. The College recommends that obstetrician–gynecologists annually review patients' risk factors for HIV and assess the need for retesting. Repeat HIV testing should be offered at least annually to women who have the following risk factors:

  • Are injection drug users
  • Have sex partners who are injection drug users or are infected with HIV
  • Exchange sex for drugs or money
  • Have received a diagnosis of another sexually transmitted infection (STI) in the past year
  • Have had more than one sex partner since their most recent HIV test.

Obstetrician–gynecologists also should encourage women and their prospective sex partners to be tested before initiating a new sexual relationship. In addition,periodic retesting could be considered even in the absence of risk factors depending on clinical judgment, geography (eg, living in a high-prevalence community), and the patient's wishes. Some patients may not always disclose or admit to high-risk behaviors or might not perceive their behaviors to be high risk.

The Centers for Disease Control and Prevention has estimated that approximately 21% of HIV-infected individuals who are unaware of their HIV infection account for 54% of new infection transmissions (9). It is estimated that informing infected individuals who are unaware of their status that they are HIV-infected could reduce the number of new STIs by more than 30% (10). Human immunodeficiency virus testing is an effective preventive intervention partly because knowing one's serostatus may lead to changes in behavior. A meta-analysis estimated that the number of cases of unprotected anal or vaginal intercourse with HIV-seronegative partners was reduced by 68% among HIV-infected individuals who knew of their positive serostatus compared with those who were unaware of their status (11). In addition, knowledge of serostatus soon after conversion allows more opportunity for treatment that can dramatically increase survival rates and potentially decrease the risk of transmission by decreasing HIV viral load. In 2006, 36% of individuals with AIDS received the diagnosis within 1 year after their first positive HIV test result, demonstrating the lost opportunities for earlier diagnosis and treatment (1).

Because of inadequate detection of HIV infection and the potential benefit of increased numbers of individuals knowing their HIV serostatus, the CDC revised its HIV testing recommendations in 2006. The Centers for Disease Control and Prevention now recommends routine voluntary HIV screening as a normal part of medical practice (12). Except when required by state law, prevention counseling and separate written consent are no longer considered necessary. Because state laws continue to change, clinicians should be familiar with their local laws. A useful resource is the Compendium of State HIV Testing Laws, which can be found at http://www.nccc.ucsf.edu/consultation_library/state_hiv_testing_laws). If counseling and written consent are not required, the patient should be notified that testing will be performed unless the patient declines (opt-out screening). From 2004 to 2007, CDC surveillance has shown a 15% increase in the number of HIV diagnoses, which is likely due in part to the CDC's revised recommendations for testing (1). For patients initially reluctant to be tested, brief behavioral counseling has been shown to improve HIV testing acceptance (13).

Diagnostic tests for HIV either detect host antibodies made against different HIV proteins or detect directly the whole virus or components of the virus (such as HIV RNA). Antibody testing begins with a sensitive screening test (eg, the enzyme immunoassay or rapid test), generally performed on blood samples. A positive screening test result needs to be followed by a confirmatory test, such as the Western blot or immunoflorescence assay (IFA). The enzyme immunoassay and Western blot testing combination is the oldest HIV diagnostic test and is readily available. When the test is used after seroconversion (usually 6–8 weeks after initial HIV infection), the test has a high sensitivity of 99.3–99.7% and a high specificity of 99.7% (14). Human immunodeficiency virus diagnostic tests performed on saliva and urine samples also are available, but the results of these tests need to be confirmed by Western blot or IFA.

Standard antibody testing can take up to 1 week or longer to complete; consequently, many HIV-infected individuals do not return for results and are lost to follow-up (15). Rapid HIV testing has the potential advantage of decreasing costs and increasing the number of patients who receive their results (16, 17). It is especially useful in venues where patients often may not return to learn their results (eg, emergency departments and urgent care clinics) and in situations where positive test results will generate immediate action (eg, during labor and delivery or after occupational exposure) (18).

Rapid tests approved by the FDA include six clinically available tests, four of which have Clinical Laboratory Improvement waivers. Sensitivity and specificity of the available tests generally exceed 99%. Only one rapid test is approved for use with oral fluid. Rapid tests are considered antibody screening tests, and positive test results require confirmatory testing with Western blot or IFA. However, in settings where urgent action is needed, such as after occupational exposure or for prevention of perinatal transmission in labor, decisions should be made based on the positive screening test result. Patients with positive rapid test results and negative or indeterminate confirmatory test results should have follow-up confirmatory testing after 4 weeks.

Gynecologic providers should consider a diagnosis of acute HIV infection in patients who have a compatible clinical syndrome, even in the absence of reported risk behaviors. An estimated 40–90% of patients acutely infected with HIV will experience fever, lymphadeno-pathy, pharyngitis, skin rash, myalgias or arthralgias, and other symptoms. When acute retroviral syndrome is suspected, a plasma HIV RNA test should be used in conjunction with an HIV antibody test for diagnosis. A low-positive HIV RNA level (less than 10,000 copies per milliliter) may represent a false-positive test result because values in acute infection generally are high (greater than 100,000 copies per milliliter) and are associated with increased risk of both perinatal and sexual transmission.

  • How are recommendations for cervical cancer screening and treatment of dysplasia different for HIV-infected women?

Women infected with HIV are at an increased risk of high-risk human papillomavirus (HPV) infection and cervical intraepithelial neoplasia (CIN) (19–21). The incidence, prevalence, and persistence of HPV, including high-risk subtypes, are more common in the setting of HIV infection and increase with worsening immunosuppression (ie, decreasing CD4 count and increasing viral load) (19, 21–23). However, among women who receive regular screening and recommended follow-up treatment, the incidence of invasive cervical cancer is not higher among HIV-infected women compared with HIV-negative women (24, 25). Therefore, women with HIV infection should have cervical cytology screening twice in the first year after diagnosis of HIV and annually thereafter (26, 27).

The optimal management of HIV-infected women with abnormal cervical cytology test results, specifically women with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesion (LSIL), remains unclear. The 2006 American Society for Colposcopy and Cervical Pathology Consensus Guidelines endorse similar management schemes for ASC-US (including the option of reflex high-risk HPV testing for triage) and LSIL irrespective of HIV status (28). However, the more recent CDC guidelines, although based on limited and conflicting data regarding the utility of HPV testing in HIV-infected women with ASC-US, recommend routine colposcopy for HIV-positive women with ASC-US or higher grade abnormality (27). In two prospective studies of HIV-infected women with ASC-US, approximately 30% of participants had evidence of oncogenic HPV, a finding that would support the use of HPV testing in this population if HPV testing remained highly sensitive (29, 30). However, one study reported a sensitivity of HPV testing for the detection of CIN 2 or higher of 100% (30), whereas another study found HPV testing to be of insufficient sensitivity (50%) for detecting high-grade CIN (29). Human papillomavirus testing currently has no role in the triage of HIV-infected women with abnormal cytology results or for follow-up after treatment for CIN.

It remains unclear whether HIV-infected women with mild cytologic abnormalities are at a similar or increased risk of clinically significant disease as compared with the uninfected population. In a cross-sectional study of HIV-infected women and non–HIV-infected women with ASC-US and LSIL, HIV-infected women were as likely as HIV-negative women to have CIN 2 or higher on biopsy (31). For HIV-infected women with ASC-US or LSIL and no histologic evidence of high-grade CIN, the absolute risk of progression to CIN 2 or higher is low (approximately 12%) (32). Among a cohort of HIV-infected women, CIN 1 was also shown to infrequently progress to more advanced disease (33). Therefore, repeat cytologic testing at 6 months and 12 months is recommended for HIV-infected women with mild cytologic abnormalities, satisfactory colposcopy results, and no evidence of histologic high-grade disease (28).

In nonpregnant women aged 21 years and older, both excision and ablation are acceptable treatment modalities in the presence of histologic diagnoses of CIN 2 or CIN 3 and satisfactory colposcopy results, regardless of HIV status (28). Women with HIV infection appear to be more likely to have persistent or recurrent disease after treatment. Glandular involvement and the presence of positive excisional margins have been associated with increased likelihood of treatment failure among HIV-infected women (34), although such associations have not been consistently seen across all studies (35). In general, excisional therapies have been shown to effectively prevent progression to invasive cervical cancer, although re-excision may be necessary in some patients (36, 37). Despite the increased recurrence rates after excisional or ablative treatment, most treatment failures and recurrences were associated with low-grade disease, which may be associated with new HPV infections (38). Follow-up with cervical cytology alone or cytology and colposcopy together at 6-month intervals over the first year after treatment is recommended (27, 28). Although HPV testing at 6–12 months is another option for follow-up, the CDC does not endorse its use in this setting (27, 28). Because of a dramatic increase in the amount of HIV shed in the genital tract 2–4 weeks after treatment for CIN, abstinence from vaginal intercourse should be emphasized until complete healing has occurred (39).

Women with HIV infection, particularly those with evidence of high-grade CIN before or at the time of hysterectomy, are at a significantly increased risk of subsequent vaginal cytologic abnormalities compared with the general population (40). Thus, continued cytologic surveillance is warranted in HIV-infected women with a history of CIN 2 or greater who undergo hysterectomy. In general, it should be noted that HIV-positive women have higher rates of anogenital neoplasia (including not only vaginal, but also vulvar and perianal neoplasia) (41, 42). Close attention should be paid to these areas for any HIV-infected woman undergoing assessment for cervical or vaginal cytologic abnormalities.

Women with HIV infection also are at an increased risk of high-grade anal intraepithelial neoplasia and anal cancer compared with the general population (27). Even with the use of HAART, high-grade anal intraepithelial neoplasia was found in 9% of HIV-infected women in a large prospective study (43). Although screening with anal cytology every 2–3 years has been shown to provide life-expectancy benefits and to be cost effective in HIV-negative homosexual and bisexual men, the benefits in women remain unclear (44). Women with HIV infection should be routinely questioned about rectal symptoms, such as bleeding or pain. Inspection and digital rectal examination may aid in the detection of anal cancer. Anal cytology should be considered if resources, such as high-resolution anoscopy, are available to evaluate and treat any abnormal findings (45). In addition, it may be necessary to examine atypical appearing genital warts or those not responding to treatment with biopsy to exclude preinvasive or invasive lesions because squamous cell carcinomas arising in or resembling genital warts might occur more frequently among immunosuppressed persons.

Although adolescents with HIV have a higher incidence of cervical dysplasia than those who do not have HIV (46–48), the incidence of high-grade abnormalities (both high-grade squamous intraepithelial lesion and CIN 2 or CIN 3) appears to be low (46). Therefore, cytologic surveillance in this population is recommended twice in the first year after diagnosis and annually thereafter, with referral for colposcopy for any cytologic abnormality other than ASC-US (27, 49). Adolescents with ASC-US may be monitored with repeat cytology alone or referred to colposcopy.

Another issue of concern in HIV-infected adolescents, a significant percentage of whom are infected perinatally, is the use of the HPV vaccine. Although data on the safety of the quadrivalent vaccine in HIV-infected children has been demonstrated, efficacy of the currently available HPV vaccines in women or girls with HIV has not yet been established (50). Human immunodeficiency virus infection is not considered a contraindication to vaccine administration, and CDC recommendations for HPV vaccination of children and adolescents should be followed for both HIV-infected and non–HIV-infected populations (27, 51, 52).

  • In HIV-infected women, how does diagnosis and treatment of bacterial vaginosis or vulvovaginal candidiasis differ from that in non–HIV-infected women?

A similar prevalence of bacterial vaginosis, as identified by Gram stain, was seen among HIV-infected and non–HIV-infected women in the Women's Interagency HIV Study sponsored by the National Institutes of Health (53). A cross-sectional study of the prevalence of bacterial vaginosis among women in the CDC-sponsored HIV Epidemiology Research Study (HERS) cohort demonstrated an increased prevalence of bacterial vaginosis among HIV-infected women identified by Gram stain (47% of women), but these results were not shown using clinical criteria.

Among the HIV-infected women, the use of antiretroviral drugs was associated with a lower prevalence of bacterial vaginosis than when antiretroviral drugs were not used (54). A longitudinal analysis of this same cohort found an increased prevalence of bacterial vaginosis, but these results were primarily thought to occur because HIV-infected women were more likely to have more persistent infections rather than more incident (ie, frequent) infections. This was particularly true for HIV-infected women with CD4 counts of less than 200 cells per cubic millimeter (55). The treatment regimens for bacterial vaginosis in HIV-infected women are the same as those for non–HIV-infected women.

Vaginal colonization with Candida albicans and vulvovaginal candidiasis are more frequent among HIV-infected women than non–HIV-infected women (53, 56). A longitudinal analysis of the HERS cohort revealed that much of this difference can be attributed to immunosuppression; rates of vulvovaginal candidiasis among immunocompetent HIV-infected women (with CD4 counts of greater than 500 cells per cubic millimeter) were similar to those in non–HIV-infected women. However, among HIV-infected women, increased rates of yeast colonization and vulvovaginal candidiasis were associated with decreasing CD4 counts (57, 58). This same study showed that although vulvovaginal candidiasis occurred with higher incidence and greater persistence among HIV-infected women, the severity of the infections was not increased.

For immunocompetent women with HIV infection, treatment of vulvovaginal candidiasis is similar to that for women without HIV infection (59). However, given the persistence of symptomatic candidiasis among HIV-infected women, topical therapies are recommended to be administered for at least 7 days, and fluconazole may be more effective when given in two sequential 150-mg doses 3 days apart (60). Long-term prophylactic therapy with fluconazole at a dose of 200 mg weekly has been shown to be effective in reducing colonization with C albicans and symptomatic vulvovaginal candidiasis in HIV-infected women, but this regimen is not recommended for routine primary prophylaxis in HIV-infected women in the absence of recurrent vulvovaginal candidiasis (59, 61).

  • In HIV-infected women, how do diagnosis and treatment of STIs differ from those for non–HIV-infected women?

With few exceptions, the prevalence and treatment of STIs are not affected by HIV serostatus. However, the presence of STIs, especially ulcerative disease, increases HIV shedding, which may increase the risk of HIV transmission to partners (62, 63). Therefore, STIs should be treated aggressively in women with HIV. The Centers for Disease Control and Prevention recommends annual screening for curable STIs (eg, syphilis, gonorrhea, and chlamydia) among sexually active HIV-infected women, with more frequent screening if indicated by symptoms or risk behaviors (59).

Large cohort studies have not shown significant differences in the prevalence of chlamydia, gonorrhea, trichomoniasis, and syphilis by HIV serostatus (64, 65). Chlamydia, gonorrhea, and trichomoniasis are diagnosed and treated among HIV-positive women using the same diagnostic criteria and treatment regimens used for the evaluation of HIV-negative women.

The Centers of Disease Control and Prevention guidelines for the treatment of pelvic inflammatory disease (PID) do not differ by HIV infection status. Whether the management of immunodeficient HIV-infected women with PID requires more aggressive interventions, such as hospitalization or administration of parenteral antimicrobial regimens, has not been adequately evaluated (59). Some studies suggest that HIV-infected women may initially have more severe symptoms, are more likely to have tubo–ovarian abscesses, or require prolonged hospital courses, but overall response to standard therapy is the same among HIV-infected and non­–HIV-infected women (66–68).

In general, management and treatment of syphilis among HIV-infected patients is the same as that among non–HIV-infected patients. Although there are reports ofunusual serologic responses among HIV-infected individuals who have syphilis, these effects are uncommon. Both treponemal and nontreponemal serologic tests for syphilis can be interpreted in the usual manner for most patients who are co-infected with Treponema pallidum and HIV (59). Human immunodeficiency virus serostatus has been shown to have a small effect on clinical manifestations of primary and secondary syphilis. Compared with non–HIV-infected patients, HIV-infected patients with primary syphilis are more likely to have multiple ulcers, and HIV-infected individuals with secondary syphilis more often have concomitant genital ulcers (69). Although some studies show no influence of HIV serostatus on successful syphilis treatment rates (70), other studies show significantly more treatment failures or longer median time to successful serologic response in HIV-infected patients (71, 72). Although HIV-infected patients who have early syphilis might be at an increased risk of neurologic complications and might have higher rates of treatment failures with currently recommended regimens, no treatment regimens for syphilis have been demonstrated to be more effective in preventing neurosyphilis in HIV-infected patients than the syphilis regimens recommended for patients witouht HIV infection (73).

Herpes simplex virus type 2 (HSV-2), the most common cause of genital ulcer disease, is more prevalent among individuals with HIV infection, with approximately 70% of HIV-infected individuals coinfected with HSV-2 (74). Accumulating epidemiologic evidence suggests that HIV acquisition and transmission are promoted by HSV-2 infection and that HIV disease progression is hastened by HSV-2 infection (75). The frequency, severity, and duration of HSV-2 clinical reactivation and frequency of subclinical infection are all increased by HIV infection. Although HAART reduces the severity and frequency of symptomatic genital herpes, HIV-infected women have comparatively more genital ulcers and frequent subclinical shedding still occurs among these women receiving antiretroviral therapy (76, 77). Suppressive or episodic therapy with oral antiviral agents is effective in decreasing genital ulcers, genital HSV-2 shedding, as well as HIV genital shedding and plasma HIV viral load among coinfected women (78–83). The treatment of HSV-2 in the context of HIV-1 coinfection often requires a longer duration of treatment at higher antiviral doses. Recommendations for suppressive and episodic therapy can be found in the CDC's sexually transmitted disease treatment guidelines (59).

As previously noted, HIV-infected women are more likely to have HPV coinfection. This coinfection is manifested in the lower genital tract by the increased prevalence and incidence of genital warts compared with those of non–HIV-infected women (41, 84). Although treatment modalities for external genital warts do not differ in the setting of HIV infection, individuals who are immunosuppressed because of HIV may have larger or more numerous warts, may not respond as well as immunocompetent individuals to therapy for genital warts, and may have more frequent recurrences after treatment (84, 85).

  • In HIV-infected women, how does treatment of menstrual disorders differ from that in non–HIV-infected women?

Women infected with HIV should receive the same evaluation and treatment for menstrual disorders as uninfected women. Although menstrual disorders are frequently reported by HIV-infected women, the role of HIV and HIV-related immunosuppression in menstrual abnormalities is unclear. Some studies have shown that amenorrhea and irregular cycles are more common among HIV-infected women (86, 87). Human immunodeficiency virus serostatus was not associated with menstrual abnormalities when data were controlled for age, ethnicity, body mass index, smoking status, alcohol use, drug use, and parity. However, among HIV-positive women, those using HAART and with higher CD4 counts were less likely to have menstrual abnormalities (88). Among more immunosuppressed women (with CD4 counts of less than 200 cells per cubic millimeter), there was a suggestion of increased prevalence of long (greater than 90 days) or short (less than 18 days) cycles (89). In the setting of HIV infection, confounding variables, such as weight loss, chronic disease, substance abuse, or use of psychotherapeutic medications, may be related to menstrual disorders (90).

  • In HIV-infected women, how do the diagnosis and treatment of menopausal symptoms differ from those in non–HIV-infected women?

As life expectancies for women living with HIV increase, more HIV-infected women are experiencing the menopause transition. Although data regarding the effect of HIV on the age at menopause are not conclusive, studies suggest that the mean age at menopause for HIV-infected women is 3–4 years younger than that for uninfected women (91). A variety of factors associated with earlier menopause, including current smoking, substance abuse, African American race, lower socioeconomic level, and low relative body weight, are common among women with HIV and may be a basis for the occurrence of menopause at an earlier age (92). Baseline data from a prospective study showed that HIV infection and immunosuppression were associated with an earlier age at the onset of menopause (93). In the Women's Interagency HIV Study cohort, the age at menopause was not affected by HIV status, but prolonged amenorrhea (lasting longer than 12 months) was more common among HIV-infected women than among non–HIV-infected women. Serum follicle-stimulating hormone levels in approximately one half of the HIV-infected women with prolonged amenorrhea did not necessarily indicate menopausal status, and HIV-infected women were more than three times more likely than non–HIV-infected women to have prolonged amenorrhea without ovarian failure (94).

Low bone mineral density has been found to be more prevalent among women with HIV approaching menopause than those without HIV infection (95). Even among women with normal bone mineral density, a case–control population-based study showed that HIV-infected women reported significantly more osteoporotic fractures than women in the control group (96). Data regarding treatment of osteoporosis for HIV-infected women are lacking. Standard suggestions for treatment and prevention can be made, including increasing physical activity, stopping smoking, and taking calcium and vitamin D supplements. Small studies confirm the benefits and safety of alendronate therapy in HIV-infected patients (97).

  • How should HIV-infected women be counseled about transmission prevention?

The most effective method of avoiding sexual transmission of HIV infection is abstinence from sex (or in the case of HIV-negative women, limiting sexual contact to a mutually monogamous uninfected partner). A meta-analysis showed that consistent use of male condoms resulted in an 80% reduction in the risk of HIV transmission among HIV serodiscordant couples, and should be recommended for the prevention of HIV transmission as well as other STIs (98). Condom use also should be promoted as an adjunctive method to decrease the risk of transmission of HIV in women using other methods of contraception. Efficacy of female condoms in reducing the risk of HIV transmission remains to be demonstrated (99). Laboratory studies indicate that the female condom is an effective mechanical barrier to viruses, including HIV (100). However, a limited number of clinical studies has evaluated the efficacy of female condoms in providing protection from STIs, including HIV (101).

Although reported rarely, it is possible that continued sexual exposure to a partner with an elevated viral load may adversely affect the viral load of a patient taking HAART, and may lead to superinfection. Therefore, the couples where both partners are HIV infected should be counseled that condoms should be used to decrease the potential risk of superinfection.

Vaginal spermicides containing nonoxynol-9 are not effective in preventing HIV infection and may, in fact, increase the risk of HIV transmission secondary to associated disruption of the genital epithelium (102). Women with HIV should be screened and treated for genital infections because numerous studies have demonstrated that genital ulcer disease, cervical infections, and vaginal infections increase HIV shedding in the female genital tract and that successful treatment reduces shedding (103). In an observational study, HAART was reported to decrease the risk of heterosexual HIV transmission up to 80% among serodiscordant couples (104). However, because HIV can be detected in the semen, rectal secretions, female genital secretions, and pharynx of HIV-infected patients with undetectable plasma viral loads and because consistent reduction of viral load depends on close adherence to antiretroviral regimens, HIV-infected women, even those with undetectable plasma loads, should be counseled that they can still transmit HIV (105). Observational studies indicate that antiretroviral postexposure prophylaxis may reduce the risk of HIV infection if initiated within 72 hours of sexual exposure to an HIV-infected partner (106).

Clinicians should screen HIV-infected women for behavioral risk factors for transmission at least annually and more often if indicated (eg, if a woman has a new STI) (105). Innovative and successful interventions (emphasizing cognitive theory and the theory of gender and power) to decrease risk taking by HIV-infected patients have been developed for diverse populations (107). For example, a trial (among heterosexual non–HIV-infected patients at STI clinics) found that two 20-minute enhanced counseling sessions (Project RESPECT) led to increased self-reported condom use and decreased rate of incident STIs compared with patients who received didactic messages only (108). The underlying principle of providing effective risk-reducing counseling is to individualize the message provided to the patient receiving the counseling. Behavioral interventions targeting adult and adolescent women of color are crucial to decrease rates of morbidity and mortality from HIV and AIDS (2).

  • What methods of contraception are the most effective for women with HIV and what methods are contraindicated?

Women infected with HIV require highly effective contraception that is compatible with HAART regimens (if applicable), places them at low risk of acquiring STIs, and does not increase their risk of transmitting HIV to their partners (Table 1 and Table 2).

Table 1. Summary of Risk Classifications for the Use of Hormonal Contraceptive Methods and Intrauterine Devices
Condition Combined Hormonal Contraceptive: Oral, Patch, and Ring Progestogen-Only Pill DMPA Implants
Levonorgestrel-Containing IUD
Copper IUD
Initiation Continuation Initiation Continuation 
 
HIV and AIDS
High risk of HIV infection
1
1
1
1
2 2 2 2
HIV infection
1
1
1
1
2 2 2 2
AIDS
1
1
1
1
3 2 3 2
Clinically well on antiretroviral therapy If taking antiretroviral therapy, refer to the section on Antiretroviral Therapy 3 2 3 2
 
Antiretroviral Therapy
 
Nucleoside reverse transcriptase inhibitors
1
1
1
1
2/3  2 2/3 2
Nonnucleoside reverse transcriptase inhibitors
2
2
1
2
2/3 2 2/3 2
Ritonavir-boosted protease inhibitors
3
3
1
2
2/3 2 2/3 2

AIDS indicates acquired immunodeficiency syndrome; DMPA, depot medroxyprogesterone acetate; HIV, human immunodeficiency virus; IUD, intrauterine device.

Categories of Medical Eligibility Criteria for Contraceptive Use

1 = A condition for which there is no restriction for the use of the contraceptive method
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
4 = A condition that represents an unacceptable health risk if the contraceptive method is used

Farr S, Folger SG, Paulen M, Tepper N, Whiteman M, Zapata L, et al. U.S. medical eligibility criteria for contraceptive use, 2010: adapted from the World Health Organization Medical eligibility criteria for contraceptive use, 4th edition. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Centers for Disease Control and prevention (CDC), MMWR Recomm Rep 2010;59(RR-4):1–86. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf. Retrieved July 27, 2010.

Hormonal contraception is safe in women with HIV. Two prospective cohort studies have assessed the safety of hormonal contraception among HIV-infected women. Postpartum HIV-infected Kenyan women using oral contraceptives (OCs) or depot medroxyprogesterone acetate (DMPA) showed no differences in HIV RNA load or absolute levels or a decrease in CD4 count compared with those of women not using hormonal contraception (109). In the Women's Interagency HIV Study, HIV-infected U.S. women using hormonal contraception (OCs, DMPA, or progestin contraceptive implant) had similar HIV RNA levels and minor increases in CD4 count compared with women not using hormonal contraception (110).

For women using HAART, there are some concerns regarding the efficacy of hormonal contraception. Hormonal contraceptives are primarily metabolized via sulphate and glucoronide conjunction in the liver and also are metabolized through cytochrome P450 enzymes. Human immunodeficiency virus antiretroviral agents have varying effects on these metabolic pathways (Box 2). The data on the interactions of specific hormonal contraceptives and HIV antiretroviral agents is limited and type specific. For women taking certain HAART regimens, combined OCs generally are not recommended because of potential alterations in the hormonal contraceptive and the antiretroviral drug (111, 112). Specifically, for women taking ritonavir-boosted protease inhibitors, combined OCs generally are not recommended due to potentially decreased efficacy of the contraceptive (112, 113). Also, the nonnucleoside reverse transcriptase inhibitor nevirapine reduced levels of combined OCs (ethinyl estradiol and norethindrone) when coadministered (114). But women taking nonritonavir-boosted atazanavir or indinavir, or using the nonnucleoside reverse transcriptase inhibitor efavirenz may be able to use combined OCs without a loss of efficacy(111). Up-to-date information regarding drug interactions with antiretroviral agents can be found at http://hivinsite.ucsf.edu/insite?page=ar-00-02 and http://www.hiv-druginteractions.org.

Table 2. Summary of Risk Classifications for the Use of Barrier Methods of Contraception
Condition
Method
Condom         Spermicide      Diaphragm
Comments
High risk of HIV
1
4
4
Repeated and high-dose use of the spermicide nonoxynol-9 was associated with increased risk of genital lesions, which may increase the risk of HIV infection*.
Diaphragm use is assigned Category 4 because of concerns about the spermicide, not the diaphragm.
HIV Infection
1
3
3
Use of spermicides or diaphragms (with a spermicide) can disrupt the cervical mucosa, which may increase viral shedding and HIV transmission to uninfected sex partners.
AIDS
1
3
3
Use of spermicides or diaphragms (with a spermicide) can disrupt the cervical mucosa, which may increase viral shedding and HIV transmission to uninfected sex partners.

AIDS indicates acquired immunoeficiency syndrome; HIV, human immunodeficiency virus.

Categories of Medical Eligibility Criteria for Contraceptive Use

1 = A condition for which there is no restriction for the use of the contraceptive method
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
4 = A condition that represents an unacceptable health risk if the contraceptive method is used

*Wilkinson D, Ramjee G, Tholandi M, Rutherford G. Nonoxynol-9 for preventing vaginal acquisition of HIV infection by women from men. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD003936. DOI: 10.1002/14651858.CD003936.

Farr S, Folger SG, Paulen M, Tepper N, Whiteman M, Zapata L, et al. U.S. medical eligibility criteria for contraceptive use, 2010: adapted from the World Health Organization Medical eligibility criteria for contraceptive use, 4th edition. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Centers for Disease Control and prevention (CDC), MMWR Recomm Rep 2010;59(RR-4):1–86. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf. Retrieved July 27, 2010.

Generally, the U.S. Department of Health and Human Services recommends additional or alternative (non-oral hormonal) contraception for HIV-infected women taking most nonnucleoside reverse transcriptase inhibitors or protease inhibitors and recommends against coadministering combined OCs with fosamprenavir secondary to a decrease in the blood level of the antiretroviral agent when coadministered (6). The Centers for Disease Control and Prevention advises the use of condoms if combined OCs are used in combination with antiretroviral therapy (112). Depot medroxyprogesterone acetate was found to have no interactions with several antiretroviral agents, including efavirenz, nevirapine, and nelfinavir, and is considered safe and effective for use by HIV-infected women (115, 116). No studies have examined the interaction of other types of hormonal contraception (eg, subdermal implant, vaginal ring, and contraceptive patch) with antiretroviral agents, so the same precautions as used with combined OCs are recommended.

Box 2. Oral Contraceptives and Antiretroviral Therapy

Antiretroviral Agents That Decrease Hormone Levels

  • Ritonavir, nelfinavir, lopinavir—40–50% decrease in ethinyl estradiol levels. Alternative or additional method of contraception should be used.
  • Amprenavir—decrease in ethinyl estradiol and norethindrone levels. Because the oral contraceptive agents decrease the amprenavir levels by 20%, the agents should not be coadministereded and an alternative method of contraception should be used.
  • Nevirapine—20% decrease in ethinyl estradiol levels. Alternative or additional method of contraception should be used.

Antiretroviral Agents That Increase Hormone Levels

  • Efavirenz—37% increase in ethinyl estradiol levels; clinical significance unknown. Alternative or additional method of contraception should be used.
  • Atazanavir—48% increase in ethinyl estradiol levels and 110% increase in norethindrone levels. The lowest effective dose or alternate method of contraception should be used.
Data from Anderson JR. Approach to the patient. In: Anderson JR, editor. A guide to the clinical care of women with HIV. Rockville (MD): Health Resources and Services Administration; 2005. p. 35–46.

Intrauterine devices (IUDs) are a good contraceptive method for HIV-infected women. A randomized study showed the copper IUD is safe and effective for use in HIV-infected women, with a higher rate of efficacy compared with combined OCs, and was associated with only one case of PID (0.16 cases per 100 woman-years) (117). A prospective cohort study showed no association between HIV infection and complications in the first 2 years of using a copper IUD (118). The copper IUD was not associated with increased HIV-1 viral shedding measured 4 months after insertion in a single study (119). Data regarding the use of the levonorgestrel-containing IUD are more limited, but a small observational study of HIV-infected women using the levonorgestrel-containing IUD showed a reduction in menstrual blood loss, with no adverse effects on CD4 count or cervical cytology screening test results (120). Another small study showed no known drug interactions between the levonorgestrel-containing IUD and HAART and no increase in genital shedding of HIV RNA (121). Based on some of these studies, the CDC currently recommends that for women at high risk of HIV acquisition, HIV-infected women, HIV-infected IUD users converting to an AIDS diagnosis, and women with AIDS who are clinically well while taking HAART, the copper and levonorgestrel-containg IUDs may be used (112).

Recommendations for sterilization of HIV-infected women are no different than those for non–HIV-infected women. As with other medical conditions, consideration should be given to optimizing a patient's health status before elective surgery.

In addition to methods to avoid unintended pregnancy, women with HIV should be counseled regarding the need to protect themselves from STIs and to prevent HIV transmission to uninfected partners. Although condoms are the only effective method of avoiding transmission of infection with sexual intercourse, they are not a particularly effective method of contraception, with a typical failure rate of 15% over 1 year. Therefore, patients should be counseled that dual contraception (ie, the concomitant use of condoms and additional contraception) is the optimal contraceptive strategy to reduce heterosexual transmission of HIV and other STIs as well as minimizing the risk of unintended pregnancy. However, studies have shown that the more effective the other method is for pregnancy prevention, the less likely women and their partners are to combine it with condoms (122). Therefore, one strategy may be to use condoms as their primary method of birth control and of disease prevention, with emergency contraception as a backup to increase contraceptive efficacy.

  • How should patients planning to become pregnant be counseled in order to achieve optimal maternal and fetal health?

The advent of HAART and the reduction of mother-to-child transmission of HIV over the past decade to achievable rates of less than 1% have allowed HIV-infected women to live longer and healthier lives and to have more fertility options. A cohort study reported that HIV-infected women have similar reproductive patterns as non–HIV-infected women, with most already having children and many wanting children in the future (123). The Women's Interagency HIV Study cohort study showed that after HAART became available, the live birth rate among HIV-infected women was 150% higher compared with only 5% higher among similar non–HIV-infected women during the same period (124). Accordingly, reproductive plans, including preconception counseling and counseling regarding reversible methods of contraception, if appropriate, should be discussed with HIV-infected women of childbearing age.

Similar to preconception counseling for non–HIV-infected women, the goals for HIV-infected women are to improve the health of the women before conception and to identify risk factors for adverse maternal and fetal outcomes. Safe sex practices and avoidance of STIs should be discussed. Risky behaviors, such as smoking and substance abuse, should be reduced and the use of folic acid before conception should be recommended. Overall health should be optimized, and health care should be coordinated with other health care providers to ensure that hepatitis A, hepatitis B, pneumococcal, and influenza vaccinations have been provided as recommended by the CDC (125).

Preconception counseling of HIV-infected women should include a detailed discussion of interventions to reduce the risk of mother-to-child transmission, ways to optimize their long-term health, and the possible effects of antiretroviral medications on the fetus. For women taking HAART, attainment of a stable, maximally suppressed viral load before conception is recommended (126). Data regarding the effects of antiretroviral drugs on the developing fetus are limited, and the benefits and potential risks of HAART during pregnancy should be discussed with the patient. Efavirenz is the only antiretroviral agent with a strongly suggested teratogenic risk, and it should be avoided in the first trimester (7). Therapy-associated side effects (eg, hyperglycemia, anemia, and hepatic toxicity) that can affect maternal–fetal health also should be considered. All HIV-infected women considering pregnancy should be counseled regarding the availability of measures to decrease the risk of vertical transmission of HIV, including treating all HIV-infected pregnant women with HAART with the goal of reaching undetectable HIV RNA levels at the time of delivery, cesarean delivery for HIV-infected women failing to achieve viral suppression of an HIV RNA level of less than 1,000 copies per millimeter, avoidance of breastfeeding, and providing newborns with prophylactic antiretroviral medications for several weeks (127). Methods to prevent transmission of HIV to uninfected partners also should be discussed. For an HIV-infected woman in a discordant relationship who wishes to conceive, insemination of her partner's sperm at the time of ovulation will avoid HIV transmission risk through unprotected intercourse. For discordant couples in which the male is HIV-infected, assisted conception with either sperm washing for insemination or intracytoplasmic sperm injection (ICSI) may be safer than timed unprotected intercourse with regard to HIV transmission (128). Donor insemination with sperm from a non–HIV-infected male remains the safest option to avoid transmission. In a prospective study conducted before HAART therapy was available, the authors studied discordant couples trying to conceive through unprotected intercourse limited to the fertile period of the woman's cycle; 4% of women seroconverted (129). In a retrospective study of 62 discordant couples in Spain, in which the infected partner had suppressed HIV replication (less than 500 HIV copies per milliliter) and used HAART therapy before conception, no transmissions were observed (130). Sperm washing is a potential way to conceive while reducing the risk of infection to the HIV-negative woman. In reports of more than 3,000 cycles of sperm washing combined with intrauterine insemination, in vitro fertilization, or ICSI, no cases of seroconversion in either female partner or offspring have been reported (131, 132).

The American Society of Reproductive Medicine Ethics Committee recommends that fertility services be offered to HIV-infected individuals and couples willing to use risk-reducing therapies to the extent that it is economically and technically feasible. They further recommend that “when an affected couple requests assistance to have their own genetically related child, they are best advised to seek care at institutions with the facilities that can provide the most effective evaluation treatment and follow-up” (133). However, some state laws ban assisted conception with HIV-positive sperm, and the CDC continues to discourage the use of washed semen from HIV-infected partners (134, 135). Costs associated with advanced reproductive techniques, such as in vitro fertilization and ICSI, may limit access for some couples. In addition, two more recent studies reporting no HIV transmission using washed sperm with intrauterine insemination have led many experts to recommend consideration be given to this approach (132, 136).

Summary of Recommendations and Conclusions

The following recommendation is based on good and consistent scientific evidence (Level A):

  • Condoms are recommended for the prevention of HIV transmission as well as other STIs.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
  • The American College of Obstetricians and Gynecologists recommends routine HIV screening of women aged 19–64 years and targeted screening for women with risk factors outside of that age range.
  • If counseling and written consent are not required, the patient should be notified that testing will be performed unless the patient declines (opt-out screening).
  • Human papillomavirus testing currently has no role in the triage of HIV-infected women with abnormal cytology results or for follow-up after treatment for CIN.
  • For women at high risk of HIV acquisition, HIV-infected women, HIV-infected IUD users converting to an AIDS diagnosis, and women with AIDS who are clinically well while taking HAART, the copper and levonorgestrel-containing IUDs may be used.
  • Women with HIV infection should have cervical cytology screening twice in the first year after diagnosis of HIV and annually thereafter.
  • Routine colposcopy is recommended for HIV-infected women with ASC-US or higher grade abnormality.

The following recommendations are based primarily on consensus and expert opinion (Level C):

  • Patients should be counseled that dual contraception (ie, the concomitant use of condoms and additional contraception) is the optimal contraceptive strategy to reduce heterosexual transmission of HIV and other STIs as well as minimizing the risk of unintended pregnancy.
  • For women taking certain HAART regimens, combined OCs generally are not recommended because of potential alterations in the hormonal contraceptive and the antiretroviral drug as outlined in Box 2.
  • Reproductive plans, including preconception counseling and counseling regarding reversible methods of contraception, if appropriate, should be discussed with HIV-infected women of childbearing age.
  • Repeat cytologic testing at 6 months and 12 months is recommended for HIV-infected women with mild cytologic abnormalities, satisfactory colposcopy results, and no evidence of histologic high-grade disease.
  • Couples where both partners are HIV infected shouldbe counseled that condoms should be used to decrease the potential risk of superinfection.

Resources

U. S. Department of Health and Human Services Drug and Food Information
http://www.aidsinfo.nih.gov/DrugsNew/Default.aspx.

University of California in San Francisco HIV “Warmline” referral service
Phone: 800-933-3413.

Centers for Disease Control and Prevention HIV/AIDS information
www.cdc.gov/hiv

American College of Obstetricians and Gynecologists
Tool Kit for Teen Care, Second Edition http://www.acog.org/departments/adolescentHealthCare/TeenCareToolKit/ACOGPreventCare.pdf References

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The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985–April 2010. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetrician–gynecologists were used.

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I Evidence obtained from at least one properly designed randomized controlled trial.

II–1 Evidence obtained from well–designed controlled trials without randomization.

II–2 Evidence obtained from well–designed cohort or case–control analytic studies, preferably from more than one center or research group.

II–3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A—Recommendations are based on good and consistent scientific evidence.

Level B—Recommendations are based on limited or inconsistent scientific evidence.

Level C—Recommendations are based primarily on consensus and expert opinion.

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Gynecologic care for women with human immunodeficiency virus. Practice Bulletin No. 117. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;117:1492–1509.