Guide Women at Risk: Issues in the Primary Prevention of AIDS

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Women with HIV can decrease the risk of transmission by making behavioral changes, using condoms, and consistently using antiretroviral therapy. The CDC provides detailed guidance for clinicians about how to counsel patients with HIV regarding transmission prevention Women with HIV should be screened for risk behaviors and offered behavioral interventions annually, and more frequently if necessary, to reduce high-risk sexual and drug behaviors that can transmit HIV 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 The underlying principle of providing effective risk-reducing counseling is to individualize the message provided to the patient.

Behavioral interventions that target women and adolescents in high-risk populations are crucial to decrease rates of morbidity and mortality from HIV and AIDS. The CDC provides a compendium of evidence-based interventions and best practices for HIV prevention, which includes individual and group counseling, discussion, role play, written material, and interactive media behavioral interventions, many of which were validated in women living with HIV Women living with HIV should be counseled about serosorting and seropositioning and their limitations.

Serosorting is the practice of limiting unprotected sex to partners believed to have the same HIV status. Although the risk varies with the type of sexual activity, there is risk of transmission with all types Women with HIV generally should not use vaginal spermicides that contain nonoxynol-9 because they may increase the risk of HIV transmission by disrupting the genital epithelium 88 , Women with HIV should take antiretroviral therapy, with the goal of achieving a fully suppressed HIV viral load, for their own benefit and to decrease transmission to uninfected partners.

In a meta-analysis of 11 cohorts of 5, heterosexual discordant couples, the rate of transmission per person-years from infected partners treated with antiretroviral therapy was 0. The study was not able to calculate separately female-to-male and male-to-female transmission risks. Human immunodeficiency virus can at times be detected in the semen, rectal secretions, female genital secretions, and pharynx of HIV-infected patients with undetectable plasma viral loads, and consistent reduction of viral load depends on close adherence to antiretroviral regimens.

A seronegative male partner of an HIV-infected woman should consider use of antiretroviral preexposure prophylaxis with a daily fixed dose of oral tenofovir disoproxil fumarate and emtricitabine to reduce the risk of HIV acquisition 83, 91 , This combination was approved by the U. Efficacy of preexposure prophylaxis for decreasing transmission is supported by six randomized trials in a number of populations Given its safety and effectiveness, women living with HIV should be counseled that their uninfected partners should be informed about the availability of preexposure prophylaxis If preexposure prophylaxis is used, the importance of adherence and periodic HIV testing should be emphasized.

Women infected with HIV should be counseled on the availability of nonoccupational postexposure prophylaxis for uninfected partners when clinically indicated on a one-time or infrequent basis to reduce the risk of HIV acquisition in the event of inadvertent sexual or parenteral HIV exposure within the past 72 hours eg, unprotected intercourse, condom breakage, shared drug-injection equipment The CDC provides guidance for administration of nonoccupational postexposure prophylaxis, which should include two or three antiretroviral medications, and be continued for 28 days Individuals taking nonoccupational postexposure prophylaxis require follow-up HIV testing 92, Partners taking nonoccupational postexposure prophylaxis two or more times in the past year should be offered preexposure prophylaxis The U.

Department of Health and Human Services and the CDC recommend that all women with HIV who do not desire pregnancy be offered effective and appropriate contraceptive methods to reduce the likelihood of unintended pregnancy. No contraceptive methods are contraindicated, but there are special considerations about drug interactions with antiretroviral therapy regimens, risk of acquiring STIs, and risk of transmission of HIV to their partners. Patients should be counseled that dual contraception the concomitant use of condoms and an additional contraception method is the optimal contraceptive strategy to reduce heterosexual transmission of HIV and other STIs and to minimize the risk of unintended pregnancy.

Condoms also are recommended to increase contraceptive efficacy when certain antiretroviral therapy regimens are used with certain types of hormonal contraception Despite the recommendation for highly effective contraception among HIV-infected women not desiring pregnancy or on certain antiretroviral therapy regimens, condoms are the most commonly relied upon method among women with HIV, who are less likely than their seronegative counterparts to use highly effective contraception, including intrauterine devices IUDs Spermicides and diaphragms if used with spermicides generally are not recommended because of an increased risk of HIV transmission to uninfected partners with use of nonoxynol-9 containing spermicides Hormonal contraception—including combined hormonal methods pill, patch, and ring , the progestin-only pill, injection, implant, and levonorgestrel-releasing IUDs—generally is considered safe for use by HIV-infected women, including those who use antiretroviral therapy.

A systematic review of 11 studies by the World Health Organization 98 , which was updated with three additional studies in 99 , showed no evidence of HIV disease progression or increased risk of death associated with the use of hormonal contraception methods, including combined hormonal methods, progestin-only pill, injections, implants, and levonorgestrel-releasing IUDs.

The updated meta-analysis showed an adjusted hazard ratio for a composite measure of HIV disease progression of 0. Analysis of transmission risk is difficult because of potential confounding by differential condom use between hormonal contraceptive users and nonusers. Current studies of HIV transmission risk with hormonal contraceptive use are inconclusive, but the studies included in the World Health Organization systematic review did not find a significantly increased risk of female-to-male HIV transmission 98, Gynecologic care providers should consider drug-specific interactions between antiretroviral therapy and certain hormonal contraceptives when counseling patients about which method of hormonal contraception might be best for them.

There are a number of known drug interactions between antiretroviral therapy and hormonal contraception. Hormonal contraceptives primarily are metabolized through sulphate and glucuronide conjugation in the liver and also are metabolized through cytochrome P enzymes. Human immunodeficiency virus antiretroviral agents have varying effects on these metabolic pathways.

The data on the interactions between specific hormonal contraceptives and HIV antiretroviral agents are limited, particularly studies that report clinical outcomes such as pregnancy and are drug specific. The co-administration of the nonnucleoside reverse transcriptase inhibitor efavirenz with combined hormonal contraceptives may lead to decreases in contraceptive hormone levels Combined hormonal contraception and progestin-only pills generally are considered safe for use by women using efavirenz U. Combined hormonal contraception and progestin-only pills may have decreased contraceptive hormone levels in women taking certain ritonavir-boosted and unboosted protease inhibitors Despite a potential small decrease in efficacy, these methods are still generally safe for use by women with HIV The exception is fosamprenavir; there are concerns that the decreased levels of fosamprenavir associated with the use of combined hormonal contraceptives may lead to decreased efficacy of the antiretroviral drug.

Therefore, the risks of use of combined hormonal contraceptives outweigh the benefits in HIV-infected women who take fosamprenavir MEC category 3 Efavirenz may decrease the efficacy of contraceptive implants — Despite a potential small decrease in contraceptive effectiveness, implants remain highly effective, and the advantages of use by women concurrently using efavirenz generally outweigh the theoretical or proven risks MEC 2 There are theoretical concerns that interactions between ritonavir-boosted protease inhibitors, fosamprenavir, or nelfinavir and implants may reduce effectiveness of the implant; however, the advantages of implant use generally outweigh the theoretical or proven risks MEC category 2 Evidence does not demonstrate significant interactions between nevirapine and implants — Depot medroxyprogesterone acetate DMPA can be prescribed to women with HIV because it is considered safe MEC category 1 and effective for use by HIV-infected women and does not appear to have drug interactions with antiretroviral medications There is theoretical concern that interactions between fosamprenavir and hormonal contraceptives may decrease the effectiveness of fosamprenavir; however, the advantages of use of DMPA generally outweigh the theoretical or proven risks MEC category 2 No drug interactions have been demonstrated with concurrent use of DMPA and several other antiretroviral medications 95, , In women who are not clinically well or not using antiretroviral drugs, the advantages of IUD initiation generally outweigh the theoretical or proven risks MEC category 2 , and IUD continuation is considered safe MEC category 1.

There are no known drug interactions between copper or levonorgestrel-releasing IUDs These recommendations were made on the basis of review of data from eight studies of the copper and levonorgestrel-releasing IUDs in HIV-infected women A randomized trial showed the copper IUD is safe and effective for use in HIV-infected women, with a higher rate of efficacy compared with combined oral contraceptives and with a low rate of pelvic inflammatory disease 0.

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A prospective cohort study showed no association between HIV infection and complications in the first 2 years of using a copper IUD Very limited evidence suggests a low risk of pelvic inflammatory disease among women with HIV who use IUDs and no increased risk of pelvic infectious complications compared with women not infected with HIV —, — Emergency contraception, including emergency contraceptive pills progestin-only, ulipristal acetate, and combined oral contraceptives and the copper IUD, should be offered to HIV-infected women in appropriate cases, just as it would be offered to women without HIV.

For most medical conditions, the benefits of emergency contraception are considered to outweigh the risks 95, Concerns about drug interactions between some antiretroviral therapy regimens and emergency contraceptive pills exist that are similar to the concerns for combined hormonal contraception The only known study of the use of emergency contraceptive pills in women who received antiretroviral therapy showed a decrease in levonorgestrel levels when given with efavirenz There are no studies of interactions of antiretroviral therapy regimens with ulipristal acetate, but interactions could be present because of similar metabolic pathways As with other patients, the decision to have sterilization in the setting of HIV should be voluntary and noncoerced.

All reproductive-aged women living with HIV should receive prepregnancy counseling if considering pregnancy.

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Women should be counseled that they should be receiving treatment with antiretroviral therapy and have a viral load below the limit of detection before becoming pregnant. A cohort study reported that HIV-infected women have similar reproductive patterns to non-HIV-infected women, with most already having children and many wanting children in the future Similar to prepregnancy counseling for non-HIV-infected women, the goals for HIV-infected women are to improve the health of the women before pregnancy and to identify risk factors for adverse maternal and fetal outcomes.

Safe sex practices and avoidance of STIs should be discussed, and both partners should be screened for STIs, which should be treated if present. Risky behaviors, such as smoking and substance abuse, should be reduced and the use of folic acid before pregnancy should be recommended. Overall health should be optimized and health care should be coordinated with other health care providers to ensure vaccinations are up to date Any HIV-infected woman contemplating pregnancy should be counseled that she should be receiving treatment with antiretroviral therapy, with the goal of a plasma viral load suppressed to an undetectable level before achieving pregnancy Regimens without efavirenz should be considered if an HIV-infected woman is considering pregnancy.

Therapy-associated adverse effects eg, hyperglycemia, anemia, and hepatic toxicity that can affect maternal—fetal health should be evaluated and managed. All women with HIV who are considering pregnancy should be encouraged to start prenatal care early and should be counseled about the availability of measures to decrease the risk of vertical transmission of HIV, including treating all HIV-infected pregnant women with antiretroviral therapy with the goal of reaching undetectable plasma HIV RNA levels before pregnancy, the need for cesarean delivery for HIV-infected women who fail to achieve plasma HIV RNA level of less than 1, copies per millimeter by 36 weeks of gestation, avoidance of breastfeeding, and providing newborns with prophylactic antiretroviral medications for several weeks Serodiscordant couples should receive information about the risks of sexual and perinatal transmission and about safer methods to become pregnant.

Human immunodeficiency virus-negative partners of HIV-infected women should be counseled that the lowest risk of infection is achieved through homologous artificial insemination , including the option of self-insemination in the periovulatory period Couples who wish to become pregnant naturally should be educated about timed, periovulatory unprotected intercourse after the partner with HIV has achieved maximal viral suppression with antiretroviral therapy These recommendations also contain guidance for serodiscordant couples in which the male is HIV infected Costs associated with advanced reproductive techniques, such as in vitro fertilization and intracytoplasmic sperm injection, may limit access for many couples.

In the event of an unintended pregnancy, patients should be counseled about pregnancy options, including parenting, adoption, and abortion, and should be referred for such counseling.

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For patients who wish to continue their pregnancy, appropriate care to optimize maternal and pregnancy outcomes should be initiated immediately Obstetrician—gynecologists and other gynecologic care providers who treat adolescents with HIV need to use interviewing and counseling techniques that are appropriate to the cognitive level of adolescents and that take into consideration the social context of adolescents living with HIV. With advancements in antiretroviral therapy, the number of adolescent survivors of perinatal HIV infection continues to grow.

Holistic care is interdisciplinary and often includes social workers, psychologists, and peer support groups along with medical services to encourage retention of patients in care and adherence to treatment, which is particularly challenging among adolescents. Health care providers need to be aware of the social context of adolescents with HIV. Poor adherence to antiretroviral drug regimens is a common issue in the treatment of HIV-infected adolescents and young adults — Adolescents with HIV in whom substance abuse and mental health problems are concomitantly diagnosed may need to be treated for these conditions before their HIV infection can be managed A practitioner who provides obstetric and gynecologic services may need to provide care to HIV-infected adolescents and, thus, should be knowledgeable about the treatment options available in their communities, be able to educate individuals with HIV about the illness, and know where to refer their patients for support services typically provided by specialists who care for HIV-infected patients.

When caring for adolescents, disclosure issues need to be considered. Physicians should be familiar with the federal and state laws that affect confidentiality in the provision of health care to HIV-infected adolescents, including the Health Insurance Portability and Accountability Act privacy rule. Clinicians should contact their local health departments for information on reporting infectious diseases and partner notification.

During interviews with adolescents, it is important to share the limitations of confidentiality. Adolescence is a natural time for the exploration of sexuality.

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This process may be particularly complex and confusing for a young person who is infected with HIV. Adolescents who are infected with HIV should receive counseling and care that allows them to realize their sexual and reproductive goals while maximizing their personal health and minimizing the risk of unintended pregnancy, acquisition of new STIs, and transmission of infection to partners or offspring.

The following recommendations are based on good and consistent scientific evidence Level A :. The following recommendations are based on limited or inconsistent scientific evidence Level B :. The following recommendations are based primarily on consensus and expert opinion Level C :. All rights reserved. Gynecologic care for women and adolescents with human immunodeficiency virus. Practice Bulletin No. American College of Obstetricians and Gynecologists. Obstet Gynecol ;e89— Women's Health Care Physicians. Clinical Considerations and Recommendations What are the special considerations for antiretroviral drug therapy in nonpregnant women infected with HIV?

Efavirenz An animal study and case reports have suggested an increased risk of central nervous system birth defects with efavirenz 7.

How are recommendations for managing human papillomavirus-related disease different for women infected with HIV? The Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents recommends that women who are HIV-infected should have age-based cervical cancer screening as follows 11 : In women and adolescents with HIV, initiation of cervical cancer screening with cytology alone should begin within 1 year of onset of sexual activity or, if already sexually active, within the first year after HIV diagnosis but no later than 21 years of age.

In women infected with HIV who are younger than 30 years, if the initial cytology screening result is normal, the next cytology screening should be in 12 months. If the results of three consecutive annual cervical cytology screenings are normal, follow-up cervical cytology screening should be every 3 years.

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Co-testing cervical cytology and human papilloma- virus [HPV] screening is not recommended for HIV-infected women younger than 30 years. Women infected with HIV who are 30 years and older can be screened with cytology alone or co-testing. After women screened with cytology alone have had three consecutive annual test results that are normal, follow-up screening can be every 3 years. Women infected with HIV who have one negative co-test result normal cytology and HPV negative can have their next cervical cancer screening in 3 years.

Women with HIV who have cervical cytology results of low-grade squamous intraepithelial lesions or worse should be referred for colposcopy.

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For women with HIV infection who are 21 years or older and have atypical squamous cells of undetermined significance ASC-US test results, if reflex HPV testing results are positive, referral to colposcopy is recommended. If HPV testing is not available, repeat cervical cytology in 6—12 months is recommended, and for any result of ASC-US or worse on repeat cytology, referral to colposcopy is recommended. How does the diagnosis and treatment of bacterial vaginosis or vulvovaginal candidiasis differ between HIV-infected and non-HIV-infected women?

Bacterial Vaginosis Bacterial vaginosis appears to be more prevalent and persistent among women infected with HIV as compared with uninfected women 24, How do diagnosis and treatment of sexually transmitted infections differ in HIV-infected women compared with non-HIV-infected women? Chancroid Patients infected with HIV with chancroid should be treated with the same regimens as noninfected women, but they need to be monitored closely because they are more likely to experience treatment failure which can occur with all regimens and have lesions that heal slowly.

Syphilis Women infected with HIV should be screened with syphilis testing at entry to care and at least annually thereafter. Gonorrhea and Chlamydial Infection Women infected with HIV and with gonorrhea or chlamydial cervicitis should receive the same management as women without HIV infection Pelvic Inflammatory Disease Duration and choice of antimicrobial regimens for pelvic inflammatory disease do not differ in women with HIV infection Trichomoniasis Women with HIV should be screened for trichomoniasis at entry to care and at least annually thereafter.

Ectoparasites Women infected with HIV that have pediculosis pubis or scabies should receive the same treatment as noninfected women. How do the diagnosis and management of menopausal symptoms differ between HIV-infected women and non-HIV-infected women? How should HIV-infected women be counseled about transmission prevention? What is the role of preexposure prophylaxis and postexposure prophylaxis in preventing HIV transmission?

go to link What methods of contraception are the most effective for women with HIV, and what methods are contraindicated? Combined Hormonal Contraception and Progestin-Only Pills The co-administration of the nonnucleoside reverse transcriptase inhibitor efavirenz with combined hormonal contraceptives may lead to decreases in contraceptive hormone levels Contraceptive Implants Efavirenz may decrease the efficacy of contraceptive implants — Emergency Contraception Emergency contraception, including emergency contraceptive pills progestin-only, ulipristal acetate, and combined oral contraceptives and the copper IUD, should be offered to HIV-infected women in appropriate cases, just as it would be offered to women without HIV.

How should patients who are planning to become pregnant be counseled in order to achieve optimal maternal and fetal health? Are there special considerations when caring for adolescents with HIV?