Helene Bernstein, M.D., Ph.D Assistant ProfessorDepartment of Obstetrics and Gynecology David Geffen School of Medicine at UCLA March 8, 2005

1. Reproductive Health in HIV
Infected Women
Helene Bernstein, M.D.,Ph.D.
Assistant Professor
Department of Obstetrics and Gynecology
David Geffen School of Medicine at UCLA

2. Global Summary of the HIV/AIDS Epidemic,
December 2001
Number of people living with HIV/AIDS Total 40 million
Adults 37.2 million
Women 17.6 million
Children 2.7 million
About 14,000 new HIV infections a day in 2001
12,000 are in persons aged 15 to 49 years, of whom:
-almost 50% are women
-about 50% are 15–24 year olds

3. Care of the HIV Infected Woman
• Primary Care
• Gynecological Care
• Obstetric Care

4. “HIV History”
• Year of diagnosis
• How HIV was acquired
• HIV status of current partner
• Prior treatment history, including viral load
and CD 4+ T cell counts on and off
therapy
• History of gynecologic problems and HIV-
affected pregnancies
• Supportive care needs

5. Preconceptual Counseling
• Educate patients about perinatal transmission
rates
• To avoid unintended pregnancies
• Counsel patients about safe methods to
conceive
• Choose anti-retrovirals which are known to be
effective in reducing perinatal HIV transmission
• Attain a stable, maximally suppressed viral load
• Optimize medical and nutritional status

6. Vaccination
• Kiiled virus, toxoid, or recombinant
vaccines are safe in pregnancy
• Routine vaccinations
– Hepatitis B
– Pneumonia vaccine
– Influenza vaccine
Rubella vaccine and other live, attenuated
vacicnes may be given post-partum

7. Gynecologic Issues in HIV Infected
Women
• Abnormal uterine bleeding
• Pap smears
• Infections/STD screening: GC, chlamydia, HSV, genital
ulcerative disease
• Contraception
• Breast Examinations-mammograms at appropriate age

8. Abnormal PAP smear:
HPV Virology and
Epidemiology
• part of a heterogeneous group of double-stranded DNA viruses
• There are over 100 subtypes of HPV, categorized depending on
their association with neoplasia and cancer.
• Common low risk subtypes of HPV are 6 and 11 (other subtypes:
42, 43, 44), which are found in condylomas.
• HPV subtypes found in cervical cancer specimens are 16 and 18
(other high risk subtypes: 31, 33, 35, 39, 45, 50, 51, 53, 55, 56, 58,
59, 64, and 68).
• HPV DNA is found in over 99% of cervical cancer specimens.
• HPV infects epithelial cells, high risk HPV genotypes integrate
into the host genome and express viral oncogenes E6 and E7
which can lead to dysplasia.

9. HPV: Virology and
Epidemiology
• Over 50% of sexually active adults have been infected with at least
one subtype of HPV, but most infections are transient
• Risk factors for developing dysplasia/cancer include: more than six
sexual partners, cigarette smoking, early age of first coitus, history
of STDs and immunosuppression
• HIV-infected women have been found to have a higher prevalence of
HPV, higher likelihood of multiple subtypes, and greater prevalence
of oncogenic subtypes than in HIV-uninfected women
• In HIV-infected women the frequency of HPV infection increases
with decreasing CD4 counts and/or higher viral loads.

10. Manifestations of HPV disease in
women
1. Abnormal PAP smear
• 30-60% of PAP smears in HIV-infected women are abnormal
• 15-40% dysplasia
• 10-11 times higher rate than HIV negative women
• Dysplasia is more likely to involve other areas of the lower genital tract
in HIV-infected women (vagina, vulva, perianal area)
• There maybe an increased rate of progression of dysplasia in HIV-
infected women
2. Invasive cervical cancer- an AIDS defining illness
• There is an increased rate of cervical cancer in HIV-infected women, particularly
those aged 20 to 34, African American and Hispanic women
• Disease is characterized by advanced stage at presentation, metastasis to
unusual locations, poor response to therapy, higher recurrence level, shorter
interval to death.
3. Other lower genital tract neoplasia

11. HPV Screening
1. PAP smears
• sensitivity and specificity is comparable to HIV-negative
women
• Would initially do every six months, then annually after two
normal PAPs, unless CD4 count is below 200.
• ThinPrep-liquid based media increases sensitivity and
decreases inadequate smears, can also perform HPV testing
using this specimen, use if possible.
2. HPV testing-make sure it will tell you subtypes!
3. Colposcopy-not recommended for screening

12. PAP Smear: Cytologic
Reporting
• Specimen adequacy: drying, inflammation
• Interpretation:
– Negative for intraepithelial lesion or malignancy
– Atypical squamous cells-of undetermined significance (ASC-US)
-cannot exclude HSIL (ASC-H)
– Atypical glandular cells-NEEDS FURTHER WORKUP
– Low-grade squamous intraepithelial lesions (LSIL) corresponds
to CIN 1
– High-grade squamous intraepithelial lesions (HSIL) combines
CIN 2, 3 and carcinoma in situ

13. Management of PAP Smears
• If abnormal PAP (anything not negative):
– Colposcopy with biopsy, look at entire lower genital tract
• If ASC or LSIL
– PAPs q4-6 months
• If HSIL/CIN 2-3
– Refer to gynecologist
– Loop electrosurgical excision procedure (LEEP), conization,
ablation (only if biopsied lesion on ectocervix)
– Post treatment: PAPs q3-4 months for 1 year then twice yearly
– Consider vaginal 5-fluorouracil cream to decrease recurrence
– HAART-regression, decrease incidence of dysplasia??
• If Cancer- Refer to gynecologic oncologist

14. Conclusions
1. Cervical dysplasia in the HIV-infected woman is
detectable and treatable
-cervical cancer can be deadly.
1. Cervical cancer can be largely prevented by regular
screening and treatment for dysplasia
2. HIV-infected patients should be evaluated for
dysplasia in other regions of the lower genital tract

15. References
Stier, E. Cervical neoplasia and the HIV-infected
patient. Hematol Oncol Clin N Am. 2003. 17:873-
87
Abularach, S. and Anderson, J. Gynecologic
problems. In A guide to the clinical care of
women with HIV.2001. pg 149-96. Available at
http://hab.hrsa.gov/publications/womencare.htm

16. Management of HIV in
Pregnancy

17. Treatment With Antiretrovirals Decreases the
Vertical Transmission Rate of HIV
• Without treatment 15-40% of babies get
HIV
• AZT reduces vertical HIV transmission by
2/3 (to 8%)
• In the US most women are treated with
HAART, leading to a HIV transmission
rate of 1%

18. HIV-Infected Pregnant Women Have Better
Outcomes than Pregnant Women With:
• Diabetes
• High Blood Pressure
• Autoimmune Diseases: Lupus

19. HIV in Pregnancy: Goals
1. Appropriate care for the mother
-therapy for maternal indications
-opportunistic infection prophylaxis and treatment
2. Limit the risk of perinatal HIV transmission

20. ART Therapy in Pregnancy
• If patient has a viral load>1000 and is willing and
able to be compliant:
– Start HAART, a typical pregnancy regimen is:
• AZT
• 3TC
• Nelfinavir
• If viral load < 1000 discuss HAART versus AZT
monotherapy with patient
• When to start?

21. Special Considerations on ART by HIV+
Pregnant Women and Their Infants
 Issues of special concern:
 Drugs with higher teratogenic risk (efavirenz, hydroxyurea).
 Combination antiretroviral therapy and preterm delivery?
 Protease inhibitors and hyperglycemia.
 Mitochondrial toxicity and nucleoside analogues:
 Pregnancy – lactic acidosis, hepatic steatosis, pancreatitis
(d4T/ddI fatalities).
 Fetus/infant – theoretical mitochondrial toxicity with in utero
exposure.

22. Maternal Factors Which Influence
Mother to Child Transmission of HIV
• Viral load
• Low CD4 Count
• Advanced HIV disease
• Pregnancy complications: preterm birth,
Chorioamnionitis, placental abruption/hemorrhage
• Sexually transmitted diseases during pregnancy
• Illicit Drug Use
• Breastfeeding
• Treatment of Maternal disease

23. Quarter-Year of Diagnosis
0
50
100
150
200
250
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
300
Perinatally Acquired AIDS Cases* by Quarter-Year
of Diagnosis, 1985-1999, United States
NumberofCases
*Adjusted for reporting delays and unreported risk; data reported through June 2000

24. Prenatal Testing
• Ultrasound
• Triple screen
• Antenatal karyotype determination if
indicated
– Patient must be counseled about the risk of
HIV transmission during procedure
– Data is limited

25. Special Considerations for
Prenatal Care
• More frequent visits,q1-4 weeks when starting therapy
• Multidisciplinary approach, involve social work, case
managers, peer counselors, pediatricians
• Check viral loads and CD4 counts monthly when starting
or changing therapy and in each trimester after viral load
becomes undetectable
• Screen for hepatitis B and C, and consider evaluating for
toxoplasmosis, CMV exposure
• Vaccinate patients as appropriate
• Emphasize adherence to antiretroviral therapy

26. Disclosure
• To partner
• To family
– Although the decision to disclose her HIV
status is that of the mother, given that the
infant will be discharged on prophylactic
medications, we encourage disclosure not
only to sexual contacts, but to close family
members who may share in the care of the
infant

27. Does an elective cesarean section
protect against HIV transmission?
• Patients on no antiretroviral therapy
• Patients on AZT monotherapy
• Patients with a measurable viral load
above 1000
• But, to be protective the elective c-section
must be done prior to labor or SROM

28. Intrapartum Management
• Goal is to minimize interval to delivery, ie
aggressively augment labor as appropriate
• Do not rupture membranes
• Avoid invasive monitoring
• Avoid episiotomy or instrumental delivery when
possible

29. Post-Partum Treatment for the
Infant
• AZT Prophylaxis for 6 weeks, medications may
be expanded dependent on maternal status
• Bactrim for 6 months, PCP prophylaxis
• Child is considered uninfected after 3 negative
viral loads

30. Studies of Potential ZDV
Carcinogenicity
• ZDV carcinogenic in vitro (all nucleosides are)
• Benign vaginal tumors in mice- probable topical effect
• Two transplacental studies in mice
– NCI: high dose, third trimester only, increased
tumors in adults
– GW: lower dose pregnancy and pups, no increase
in tumors
• Human data : No tumors in > 1,000 person-years
• Surveillance ongoing

31. Antiretroviral Pregnancy Registry
(Prospective Cases only through 1/31/02)
• • 2416 prospectively reported cases with ARV
• exposure anytime during pregnancy.
• • Birth defect rates after first trimester exposure
– ZDV 17/684 (2.5%) – Nelfinavir 8/256 (3.1%)
– 3TC 18/687 (2.6%) – Stavudine 5/250 (2.0%)
– Other agents, too few exposures to report
rates.
–
• • No pattern of defects in prospective or
• retrospective reports.