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 Perinatal 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 diseases [STDs])
- 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
Women may inherit social roles and responsibilities as caretakers for extended family members and often for friends, and may not give sufficient priority to their own medical care. Furthermore, 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. They may be fearful about disclosing their HIV status.
Sexual abuse appears to increase the risk of HIV transmission to HIV-uninfected women. For HIV-infected women, intimate partner violence and sexual coercion appear to occur at about the same rates as for HIV-uninfected women (>60% in one review). However, HIV-infected women appear to be subjected to more frequent and more severe abuse. HIV-infected women should be screened for intimate partner violence and referred to intervention services, if indicated. The U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force recommend several screening tools (see "References," below). The Abuse Assessment Screen (AAS) is one tool recommended by the CDC. It originally was intended for screening pregnant women but has since been used more widely.
Abuse Assessment Screen
- Have you ever been emotionally or physically abused by your partner or someone important to you?
- Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? If yes, by whom? How many times?
- Since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? If yes, by whom? How many times and where?
- In the last year, has anyone forced you to have sexual activities? If so, whom? How many times?
- Are you afraid of your partner or anyone you listed above?
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 Table 1.
|ARV Issues for Women||Considerations|
|ARV adverse effects||Some ARV adverse effects may be more severe in women:|
Pharmacokinetic (PK) changes:
See chapter Reducing Perinatal HIV Transmission
|Contraception||There are significant interactions between some hormonal contraceptive agents and certain ARVs; see "Contraception," below.|
Baseline 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
- Plans and desires for childbearing
- Contraception, past and current
- Date of last Papanicolaou (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
- History of STDs, 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. The incidence, prevalence, and persistence of human papillomavirus (HPV) infection and cervical, vaginal, vulvar, and anal dysplasia are more common in women with HIV infection, especially among women with low CD4 counts. 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; and perineal/perianal herpes.
Women also should be evaluated for risk of breast cancer, for contraceptive needs, and for preconception counseling
|Cervical and anal cancer screening||Women with HIV infection should have more frequent screening than uninfected women:|
|STD screening||Gonorrhea, chlamydia, syphilis at least annually, and more frequently depending on risk factors or symptom exam findings|
|Breast cancer screening||Mammography|
Clinical breast examination
|Preconception counseling||Annually or more often for all women of reproductive age|
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 STDs. Dual contraception (e.g., use of condoms plus additional contraception) is the optimal contraceptive strategy for serodiscordant heterosexual couples since it reduces the risk of transmission of HIV and other STDs as well as providing effective contraception.
*See chapter Antiretroviral Medications and Hormonal Contraceptive Agents and Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Accessed December 1, 2013.
|Male and female condom|
|Diaphragm and cervical cap|
|Injectable depot medroxyprogesterone acetate (DMPA, Depo-Provera)|
|Intrauterine devices (IUDs) (copper IUD and levonorgestrel-containing IUD)|
|Copper T IUD|
|Bilateral tubal ligation (female)|
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. The goals of preconception counseling are to improve the health of the woman prior to conception and identify, and when possible intervene around, risk factors for adverse maternal and fetal outcomes. When a woman desires pregnancy, it is important to discuss the topics listed below, with the goals of educating her and decreasing risk of HIV transmission to an HIV-uninfected partner or 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 (see below)
- Recommendations for ART before and during pregnancy, at delivery, and postpartum
- Optimization of maternal health status and suppression of HIV viral load before pregnancy
- Effect of HIV and ARVs on pregnancy and outcomes
- Effect of non-HIV-related factors (e.g., age, drug use) and other medical conditions (e.g., hypertension, diabetes, depression) on pregnancy course
- Counseling on safer sexual practices
- Counseling on other aspects of health promotion (e.g., smoking and alcohol cessation, drug treatment)
- Perinatal HIV transmission risk and prevention: ARVs for mother and infant, mode of delivery, avoidance of breast-feeding
- Treatment and care of an HIV-exposed or HIV-infected infant
- Long-term planning including advance directives and 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 the recommended techniques include the following:
- If the male partner is HIV uninfected: the woman does self-insemination of ejaculate using a syringe (no HIV exposure risk to the male partner)
- Maximal suppression of the HIV viral load of the infected partner with ART
- Screening for and treatment of STDs
- Assisted reproductive technology
- Sperm washing with polymerase chain reaction (PCR) testing and intrauterine insemination (IUI), in vitro fertilization (IVF), or intracytoplasmic sperm injection (ICSI), if the male partner is HIV infected and the female partner is HIV uninfected
The couple should be fully educated about other options, including the following:
- Preexposure prophylaxis (PrEP) for the uninfected partner
- Estimating the time of ovulation and limiting unprotected intercourse to this period, with or without use of PrEP. This approach should be considered only if HIV viremia is maximally suppressed and intercourse is limited to times when conception is most likely.
- Postexposure prophylaxis for an uninfected partner
The CDC has issued interim guidelines on use of PrEP by heterosexually active individuals as well as a fact sheet on PrEP (see "References,"). Both address the use of PrEP during attempts to conceive. Few clinical data are available at this time to guide practice; when treating serodiscordant couples who wish to conceive using PrEP, providers should review current guidelines and consult with experts in the field.
If an HIV-infected woman who is considering pregnancy initiates 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 >250 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 who may become pregnant. 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).
There is evidence that HIV-infected women may be more likely to undergo premature physiologic menopause. Earlier onset of menopause also is associated with non-HIV factors such as ethnicity and a history of intravenous drug use. Menopausal women are more at risk of premature bone loss, osteopenia, and osteoporosis; this risk may be increased by HIV infection and certain ARVs. 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 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.
- Aaron EZ, Criniti SM. Preconception health care for HIV-infected women. Top HIV Med. 2007 Aug-Sep;15(4):137-41.
- ACOG Committee on Practice Bulletins - Gynecology. ACOG Practice Bulletin No. 117: Gynecologic care for women with Human Immunodeficiency Virus. (2010). ACOG Practice Bulletin No. 117. Obstet Gynecol, 2010 Dec;116(6):1492-509. (December 2010; Reaffirmed 2012).
- Aberg JA, Gallant JE, Ghanem KG et al.; HIV Medicine Association of the Infectious Diseases Society of America. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jan;58(1):e1-e34.
- Centers for Disease Control and Prevention. Interim guidance for clinicians considering the use of preexposure prophylaxis for the prevention of HIV infection in heterosexually active adults. MMWR Morb Mortal Wkly Rep. 2012 Aug 10;61(31):586-9.
- Centers for Disease Control and Prevention, CDC Fact Sheet. PrEP: A New Tool for HIV Prevention. August 2012. Accessed January 15, 2014.
- Centers for Disease Control and Prevention, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. U.S. Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition. MMWR Recomm Rep. 2013 Jun 21;62(RR-05):1-60.
- Cejtin HE. Gynecologic issues in the HIV-infected woman. Infect Dis Clin North Am. 2008 Dec;22(4):709-39, vii.
- Collazos J, Asensi V, Cartón JA. Sex differences in the clinical, immunological and virological parameters of HIV-infected patients treated with HAART. AIDS. 2007 Apr 23;21(7):835-43.
- dePommerol, M, Hessamfar, M, Lawson-Ayayi, S, et al.; Groupe d'Epidémiologie Clinique du SIDA en Aquitaine (GECSA). Menopause and HIV infection: age at onset and associated factors, ANRS CO3 Aquitaine cohort. Int J STD AIDS. 2011 Feb;22(2):67-72.
- Hoyt, MJ, Storm DS, Aaron E, et al. Preconception and contraceptive care for women living with HIV. Infect Dis Obstet Gynecol. 2012;2012:604183.
- Kojic EM, Wang CC, Cu-Uvin S. HIV and menopause: a review. J Womens Health (Larchmt). 2007 Dec;16(10):1402-11.
- McNicholl I. Database of Antiretroviral Drug Interactions. HIV InSite. San Francisco: UCSF Center for HIV Information. Accessed December 1, 2013.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Accessed December 1, 2013.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed December 1, 2013.
- U.S. Department of Health and Human Services. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Accessed December 1, 2013.