HIV IN WOMEN.ppt

Topics
Dimension of the problem
HIV transmission in women
HIV &hormonal changes
HIV complications in women
HIV & contraception
HIV Stimga in women
HIV & pregnancy
HIV Treatment in women
Assessment & counseling
Conclusion

Topics
HIV hormonal changes
HIV & contraception
HIV Stimga in women
HIV & pregnancy
HIV Treatment in women
Conclusion

2,100,000 Number of pregnant women with HIV/AIDS
200,000 Number of pregnant women receiving PMTCT
630,000 Number of MTCT new infections
2,000,000 Number of children needing ART
315,000 Number of infections that could be averted with PMTCT
490,000 Child deaths due to AIDS (under age 14)
7 Countries where AIDS accounts for more than 10% of U5M
17% Percent of AIDS deaths among children
Global estimates relevant to Pediatric AIDS
(excluding high income countries)

Half a million women die from pregnancy-
related complications each year.
The feminization of HIV/AIDS – with the
numbers of women infected, especially
young women, rising rapidly.
Dimensions of the Problem

Almost half of the 40 million people living
with HIV today are women.
Three quarters of all new cases of HIV
are sexually transmitted between men
and women.

Contrary to the common belief that
married women are ‘safe’, many have
been infected by their only partner: In
sub-Saharan Africa, 60-80 percent of HIV-
positive women have been infected by
their husbands.

Proportion of AIDS cases in women steadily
increased since HIV epidemic began
1985 - 8% women
2004 - 27% women
Women of color disproportionately infected
Hispanic and African American women
25% of all U.S. women
80% of women with HIV in the U.S.

HIV infection in African American women in
2002:
leading cause of death for those aged 25 to 34
years
3rd leading cause of death for those aged 35–
44 years
4th leading cause of death for African
American women aged 45–54 years and for
Hispanic women aged 35–44 years
(CDC, May 2006)

Topics
HIV hormonal changes
HIV & contraception
HIV Stimga in women
HIV & pregnancy
HIV treatment in women
Conclusion

HIV Transmission in Women
Most common routes of HIV infection for
women
sex with an HIV-positive man
sharing injection drug with someone with
HIV.
Male to female transmission is 1.9 times more
effective than female to male transmission;
women are about twice as likely as a man to
contract HIV infection during unprotected
vaginal intercourse

Viral load
Viral load in women
After adjustment for differences in measurement
method, baseline CD4+ cell count, age, and clinical
symptoms, HIV-1 RNA levels were 32% to 50%
lower in women than in men at CD4+ counts >200
cells/mm3
Despite lower viral loads, HIV disease progresses at
the same rate in women as in men (Rezza et al., 2000)
Current clinical guidelines do not make a
distinction by gender for the initiation of HAART

HIV-related Hormonal Changes
HIV can affect the body's ability to produce
and maintain hormone levels
Changes in the balance of estrogen,
progesterone, or testosterone can lead to
multiple symptoms (Margolese, 2004)

Symptoms of hormonal imbalance:
Abnormal menstrual cycles, possibly
including early menopause
Weight loss
Headaches
Mood swings
Depression
HIV related hormonal changes

Symptoms of hormonal imbalance:
Sleep disturbances
Fatigue
Decreased bone density
Vaginal dryness
Lack of sexual desire
Difficulty getting pregnant
HIV related hormonal changes

Menstrual cycle changes
Increase in premenstrual symptoms
Changes may be due to
HIV itself
ARVs
other co-factors that may occur with HIV
disease such as drug use
HIV & menstrual problems

Hypermenorrhea- can predispose a woman to
anemia, already a chronic problem in women
with HIV
Amenorrhea- should be promptly evaluated
to determine possible underlying causes
pregnancy
ovarian cyst
ovarian failure and premature
menopause
HIV & menstrual problems

HIV and Menopause
The “Ms Study” examined natural history of
menopause in HIV-infected and drug using
women (Schoenbaum, 2005)
571 women, 52.9% were HIV positive
median age was 43 years
53% had a history of illicit drug use
89% were women of color

Onset of menopause significantly differed
46 years for HIV+ve women
47 years for HIV-ve women
Those with CD4+ counts <200 cells/mm3 had earliest
onset (median age 42.5 years)
No association between receipt of HAART and onset
of menopause
Earlier onset of menopause combined with HIV
disease contributes to risk of dyslipidemia and
osteopenia
HIV & menopause

AIDS Complications in Women
AIDS complications unique to women:
recurrent vaginal candidiasis
severe pelvic inflammatory disease
cervical dysplasia
cervical cancer

Women with HIV are at higher risk of
developing cervical dysplasia, a precursor to
cervical cancer
Risk is associated with immune deficiency
(declining CD4 counts and higher HIV RNA
levels
Risk is associated with human
papillomavirus (HPV) which occurs in more
than 60% of women with HIV
(Abularach & Anderson, 2005)

HIV and Cervical Cancer
Cervical Cancer
Incidence is up to 9 times higher than the
expected number of cases
Presents at more advanced stages
Metastasizes to unusual locations
Is less responsive to therapy

HIV and Oral Symptoms
Studies have shown a significant relationship
between high viral load and both oral
candidiasis and hairy leukoplakia Recurrence
and incidence of candidiasis are reduced by
HAART, and that recurrence is reduced
independent of CD4 count and HIV RNA level
HAART does not reduce the incidence of hairy
leukoplakia or oral warts in women.
(Greenspan et al, 2000; 2004; Patton et al., 2000)

Lipodystrophy Syndrome
Metabolic and clinical features include:
Insulin resistance
Impaired glucose tolerance
Type 2 diabetes
Hypertriglyceridemia
Hypercholesterolemia
Increased free fatty acids (FFA)
Decreased high density lipoprotein (HDL)
Fat redistribution
Hyperandrogenemia

Most often occurs if regimen includes
nucleoside analogues (NRTIs) and protease
inhibitors (PIs)
All HAART regimens associated with fat
redistribution
Factors that increase risk of lipodystrophy
syndrome
duration of treatment
age
degree of immune compromise
HIV & lipodystrophy syndrome

HIV+ women are nearly twice as likely as men
to have symptoms of lipodystrophy
Women tend to experience fat accumulation
in the abdomen and breasts
Men tend to experience fat depletion from
the face and extremities
HIV & lipodystrophy syndrome

HIV & Contraception
In study the effects of hormonal
contraceptives on HIV RNA and CD4 counts
1721 women 50 y.o. or less, not menopausal
controlled for CD4 count, tobacco use, age,
race, ART use, and a history of AIDS-
defining illnesses
No effect on viral load; small increase in CD4
count, not clinically significant
(Cejtin et al., 2003)

In study the effects of hormonal
contraceptives on effectiveness of HAART
77 hormonal contraceptive users matched
with non-users on age, race, and pre-HAART
CD4 count and viral load
Followed from point of HAART initiation
No effect on CD4+ cell count and viral load
responses to HAART
HIV & Contraception
(Chu et al., 2005)

Hormonal contraceptives can interact with
ARVs and cause any of the following:
decreased contraceptive effectiveness
increased concentrations of the ARV
decreased concentrations of the ARV
e.g. Amprenavir should not be co-administered
with hormonal contraceptives
Amprenavir increases blood levels of both
estrogen and progestin
oral contraceptives decrease Amprenavir
levels
HIV & Contraception

Copper IUDs
are associated with increased menstrual flow
and duration
May contributing to HIV transmission risk
May contribute to anemia in HIV+ women
HIV & Contraception

Stigma
Stigma of HIV disease has several negative
consequences
secrecy and unwillingness to disclose
serostatus
fear of being identified as HIV positive
isolation
reduced access to care
difficulties with medication adherence
unwillingness to seek social support
(Carr & Gramling, 2004)

Social Support
Social support includes the provision of
Emotional support
esteem
affiliation
Instrumental support
financial
housing
Informational support
advice
information

Women with HIV receive less social support
than demographically similar women
Social support decreases as symptoms of HIV
increase
Social support reduces psychological distress
and is a critical element in effective coping
with HIV
HIV & social support
(Hough et al., 2005)

Depression
Depression in women with HIV was 77%
Depression in PLWHIV associated with:
poorer virologic response
increased likelihood of immunologic
failure
incident AIDS defining illness
higher risk of all-cause, but not AIDS-
related, death
(Ickovics, 2001);

Depression following HAART initiation was
associated with a greater likelihood of HAART
discontinuation
Psychotherapy, pharmacotherapy or combination
of both can be used to treat depression
Self-care strategies for management of depressive
symptoms used effectively by people with HIV
include prayer, meditation, talking to others,
using distraction, and exercise
HIV & depression
(Anastos et al., 2005; Ickovics et al, 2001), (Eller et al., 2005)

Pregnancy and HIV
“When I was found [to be HIV] positive,
no one talked to me about my well-
being.The doctor told me to do MTP
[medical termination of pregnancy] as
I had no right to pass on the infection
to my baby.”
Woman in Mumbai, India, from PANOS & UNICEF, Stigma,
HIV/AIDS and Prevention of Mother-to-Child Transmission
(unnumbered page) (2001)

Worldwide, each year, two million
HIV + women become pregnant
Between 1/4 and 1/3 transmit the
disease to their newborns (2,000
new AIDS-infected infants each
day)

HIV and Pregnancy
80% of HIV+ women are of childbearing age;
consider in ART regimen selection
Care should include routine, regular education
and counseling about pregnancy/ contraception
Assess for factors associated with unplanned
pregnancies
substance abuse by the woman or her partner
mental illness
domestic violence

About 1/3 of HIV+ women and men
receiving medical care in the US desire
children in the future
20% of serodiscordant couples would
practice unsafe sex in order to conceive
HIV & pregnancy
(Klein, 2003)

HIV and Pregnancy Counseling
Impact of HIV on pregnancy course/outcome
Impact of pregnancy on HIV progression
Other reproductive issues based on maternal
factors
coexisting drug/alcohol use
advanced maternal age
hypertension, diabetes
(Anderson, 2005)

General preconception issues
nutritional counseling (e.g. folic acid)
importance of early and intense prenatal
care
Long term health of mother and care for
children (guardianship issues)
HIV & pregnancy counseling
(Anderson, 2005)

Perinatal transmission
Use of antiretrovirals and other
medications in pregnancy
Safe conception if partner HIV-negative
HIV & pregnancy counseling
(Anderson, 2005)

HIV & treatment in Women
Recommendations for treatment of women of
reproductive age:
Indications for initiation of therapy and goals
of treatment are same as for other adults and
adolescents
Avoid Efavirenz for the woman who wants to
become pregnant or who does not use effective
and consistent contraception
Panel on Clinical Practices for Treatment of HIV Infection, 2006

For the woman who is pregnant, an additional
goal of therapy is prevention of mother-to-
child transmission, with a goal of viral
suppression to <1,000 copies/mL
Selection of an ARV combination should
consider known safety, efficacy, and
pharmacokinetic data of each agent during
pregnancy
HIV & treatment in women
Panel on Clinical Practices for Treatment of HIV Infection, 2006

Pregnancy and ARV Treatment
Goals in use of ARVs during pregnancy:
- treatment of maternal infection
- reduction in the risk of perinatal transmission
Pregnant women who meet criteria as for other
adults and adolescents:
offer standard combination ARV therapy
two nucleoside reverse transcriptase inhibitors
(NRTIs) and a protease inhibitor (PI) or a
non-nucleoside reverse transcriptase
inhibitor (NNRTI) (excluding efavirenz)
(Anderson, 2005)

Considerations for ARV treatment decisions:
Treatment recommendations for health of
the woman
Known effects of ART in reducing
perinatal transmission
Known effects of ARV drug exposure on
the pregnant woman
Known effects of ARV drug exposure on
the fetus/newborn
importance of adherence to any
prescribed ARV regimen
HIV & treatment in pregnant women
(Anderson, 2005)

Drugs that cause GI upset
may not be well tolerated in early
pregnancy when morning sickness is
common
may increase risk for non-adherence
may have inadequate blood levels from
vomiting
All ARVs should be discontinued and
restarted when the nausea and vomiting is
gone or effectively treated

Protocol:
AZT + 3TC short course from 32 weeks
single dose NVP at labour
followed by 3 days of ZVD + 3TC post
partum
babies given sd-NVP at birth with ZDV x 7
days

ARV therapy can produce a significant reduction
in mother to child transmission of HIV
Studies showed that administration of AZT to
women from 14th week of pregnancy and during
labor to the newborn decreased the risk of MTCT
by nearly 70% in the absence of breastfeeding
A shorter AZT alone regimen starting from the 36th
week of pregnancy was shown to reduce the risk of
transmission of HIV at 6 months by 50% in non-
breastfeeding population and by 37% in those
breastfeeding
Zidovudine (AZT)

Pregnancy and Nevirapine
Potential side effects of nevirapine in pregnancy
Women, esp. with CD4 counts >250/mm3,
are at increased risk for symptomatic, rash-
associated, nevirapine-related hepatotoxicity
Deaths from hepatic failure reported
Early non-specific symptoms of
hepatotoxicity can be confused with
symptoms common in pregnancy

Potential side effects of nevirapine in pregnancy
 Women should be monitored for clinical
symptoms and hepatic transaminases (i.e., ALT
and AST), particularly during the first 18
weeks of therapy, when this toxicity is most
likely
Pregnancy & Nevirapine

PIs are associated with development or
worsening of hyperglycemia or diabetes
Pregnancy also increases risk for glucose
intolerance
It is not known conclusively whether the use of
PIs in pregnancy will exacerbate risk for
development of gestational diabetes
Pregnancy & protease inhibitors

For women receiving PIs in pregnancy
monitor glucose levels
ask regularly about symptoms of
hyperglycemia.
Pregnancy & protease inhibitors

Lactic acidosis and Hepatic steatosis
Lactic acidosis and hepatic steatosis (fatty
liver)
may have higher incidence in women
thought to be due to damage to
mitochondrial DNA (mitochondrial
toxicity) that is caused by long-term
nucleoside analogue use
(Arenas-Pinto et al, 2003; McComsey & Lonergan, 2004)

 Several maternal deaths due to lactic
acidosis/hepatic steatosis
 All were in women receiving combination of
d4T/ddI as part of their ART at the time of
conception and for the duration of
pregnancy
 Non-fatal cases of lactic acidosis have also
been reported in pregnant women receiving
this combination
Lactic acidosis & hepatic steatosis

Early symptoms of mitochondrial
dysfunction are nonspecific and mimic
symptoms of pregnancy:
nausea and vomiting
abdominal pain
dyspnea
weakness

Pregnant women receiving nucleoside
analogue drugs (NRTIs)
should have liver enzymes and electrolytes
evaluated more frequently during the last
trimester of pregnancy
should have new symptoms evaluated
promptly and thoroughly

Assessment and Counseling
Women infected with HIV may have more
difficulty accessing health care due to:
*Fear of disclosure
*Lack of financial resources
*Lack of transportation
*Burden of caring for others, especially
children

Women often have difficulty negotiating
protective sex due to power differentials
Lack of power may cause women to:
*Have sex against their will
*Have sex without a condom, against their will
Assessment & Counseling
(CDC, May 2006)

Lack of power may cause women to (cont.):
*Have sex with a man without knowing whether
he has high-risk behaviors (unprotected sex
with men, sex with many other partners,
injection drug use)
*Trade sex for drugs or money
*Be unable to talk to their partners about
abstinence, faithfulness, and condom use
(CDC, May 2006)

Support system: At initial visit and at intervals
assess woman’s support system
*Who knows her HIV status
*Problems encountered with disclosure
*Family and/or friends to whom she turns for
ongoing support
*Barriers to disclosure to sexual or needle-
sharing partners

Contraception:
*Discuss method of contraception
*If pregnant, discuss postpartum contraceptive
plans
*Educate and counsel about available options to
permit informed decision making
Condom use:
*Review sexual activity at each visit
*Reinforce condom use

Drug use/treatment: At initial visit and at intervals
assess past/current substance abuse (tobacco,
alcohol, illicit drugs)
*Type of substance(s)
*Amount of use
*Route of administration
*Prior drug or alcohol treatment
*Counsel about specific risks associated with
substance abuse in pregnancy. Treatment
should be encouraged and facilitated for
active problems

Adherence: Assess and reinforce importance of
adherence to prescribed medications before
they are initiated and at each visit
Clinical trials: Inform about the availability of
and offer participation in clinical trials for
which woman is eligible

Advance directives: Discuss advance directives
for care in the event of sudden deterioration
in the woman’s health
Discuss guardianship plans for children in the
event of the mother’s incapacitation or death
Facilitate legal assistance, if needed

1. HIV presentation is the same in both
sexes, but the disease has greater
implications on a woman’s reproductive
health in terms of her ability to cope with
pregnancy and transmission of the virus to
her unborn and newborn child
2. During the asymptomatic phase of HIV,
most women are unaware of their infection
until the disease is diagnosed in their
infants. This may cause conflict within the
family and the woman might be blamed
for bringing the infection into the family
Conclusions

3. The proportion of AIDS cases in women has
increased from 8% in 1985 to 27% in 2004.
4. Women of color are disproportionately infected
with HIV.
5. HIV effect on estrogen, progesterone and
testosterone leads to multiple symptoms.
Conclusions

6. HIV+ women are less likely than HIV+ men to
receive HAART.
7. Avoid efavirenz in pregnant women and those at
risk for pregnancy.
8. NRTI and PI-related lipodystrophy 2X more
common in HIV+ women vs. HIV+ men.
Conclusions

9. Contraception
Hormonal contraceptives: no sig. effect on
CD4+ count, viral load, response to HAART
IUD may increase menstrual flow, transmission
risk, anemia
10. Negative consequences of stigma include
Fear of disclosure and identification as HIV+
Isolation; reduced social support
Reduced access
Reduced adherence
Conclusions

11. Supportive and unsupportive social
interactions should be assessed.
12. HIV and pregnancy
Assess risk for unplanned pregnancy
Counsel re impact of HIV on pregnancy and
pregnancy on HIV disease
ARVs (treat maternal infection; PMTCT)
potential side effects of nevirapine, PIs
lactic acidosis, hepatic steatosis
Conclusions

13. Assess and counsel regarding:
*Support system
*Contraception
*Condom use
*Drug use and treatment
*Adherence
*Clinical trial availability
*Advance directives
*Guardianship
*Legal assistance

HIV IN WOMEN.ppt

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