Professional Documents
Culture Documents
Editors in Chief: Joseph J. Eron, Jr., MD; Daniel R. Kuritzkes, MD; Kathleen E. Squires, MD
Introduction
SUMMARY
Approximately 25% of HIV/AIDS cases in the United States today are among women, one third of
whom are 50 years of age or older
HIV-infected women tend to have higher rates of antiretroviral interruption than men
Sex-specific issues such as pregnancy and menopause have become a more important part of HIV
care as life expectancy of HIV-infected women has improved
Approximately 25% of all HIV/AIDS cases in the United States today are among women,
2013b]
[ACOG 2010]
[CDC 2013a]
have more favorable clinical parameters at primary infection diagnosis when compared with men, subsequently
women tend to have poorer clinical outcomes than men. This has been most prominent in nonwhite women
and in women from the southern United States, who progress more rapidly than other groups.
[Meditz 2011]
HIV-
infected women face the same social stressors and life-altering events that all other women face. However,
these events are further complicated by an underlying chronic medical illness that, without proper medical
treatment, is fatal. With the widespread use of potent combination antiretroviral therapy, women are now living
longer with HIV. As a result, many HIV-infected women will undergo normal life events, including pregnancy
and menopause. Although women of childbearing potential continue to encompass the majority of women
living with HIV, the number of older HIV-infected women increases each year. Tremendous progress has been
made in addressing female-specific issues surrounding HIV care. Despite these efforts, however, many
unanswered questions remain, and the HIV research and healthcare community must continue to strive to
address sex-specific care-related questions so that management of HIV-infected women continues to improve.
This module focuses on specific topics to consider in the clinical care of HIV-infected women in different life
stages. In addition, a global overview of treatment-related issues and complications specific to HIV-infected
women will be provided. For a more comprehensive overview of specific issues related to the clinical care of
HIV-infected women, please refer to the 2013 US Department of Health and Human Services
guidelines (Management Guidelines).
[DHHS Women]
For additional information from inPractice on the epidemiology in the developed world, click here.
Editors in Chief: Joseph J. Eron, Jr., MD; Daniel R. Kuritzkes, MD; Kathleen E. Squires, MD
Standard female-focused primary care should be incorporated into routine care of HIV-infected
women
Immunizations
[CDC OI]
(Management Guidelines)
[ACIP Schedule]
Hepatitis A adult vaccine for individuals without detectable immunity and at risk for
acquiring hepatitis A
Varicella virus vaccine, and zoster vaccine live may be appropriate for some individuals, but
are contraindicated for patients with CD4+ cell counts < 200 cells/mm
Primary care guidelines from HIVMA/IDSA recommend HPV vaccination for all females 9-26
years of age (Management Guidelines)
[Aberg 2014]
Anthrax vaccine adsorbed and smallpox vaccine should be avoided for all HIV-infected
women
[CDC OI]
3
Testing may be repeated in patients whose CD4+ cell count was < 200 cells/mm at initial
3
[CDC OI]
[WHO HIV]
HIV-infected patients should be screened for cardiovascular disease risk factors at each
physician visit and behavioral and pharmacological interventions initiated as appropriate
[Currier
2008]
Primary care guidelines from HIVMA/IDSA recommend annual mammography for women
aged 50 years or older, and performing individualized assessment of risk for breast cancer
followed by discussion of the risks and benefits screening mammography with women
between 40 and 49 years of age (Management Guidelines)
[Aberg 2014]
Because of the successes in identifying and treating HIV, women are now living longer with HIV infection and
are initiated on combination antiretroviral therapy at higher CD4+ cell counts. As a result, standard femalefocused primary care must be incorporated into the routine care of HIV-infected women. Clinicians must
consider that many medical complaints made by HIV-infected women are not HIV related.
Immunizations
Routine clinical care should include immunizations, and vaccine recommendations are similar between HIVpositive and HIV-negative patients. However, HIV can change the efficacy and/or safety of vaccines, and the
benefits of vaccination should be weighed against the risks to the patient.
[Parmigiani 2013]
data regarding the human papillomavirus vaccine indicate that this vaccine is both safe and immunogenic in
HIV-positive young women.
vaccine live are contraindicated for patients with CD4+ cell counts < 200 cells/mm .
[CDC OI]
[ACIP Schedule]
Hepatitis A adult vaccine (2 doses within 1-1.5 years) for individuals without detectable immunity and at risk for
acquiring hepatitis A (eg, from injection drug use, chronic hepatitis B or C infection, other chronic liver
diseases, or a bisexual partner)
Hepatitis B adult vaccine (3 doses within 6 months) for individuals without indication of past or present infection
200 cells/mm or after CD4+ cell count reaches 200 cells/mm in patients with CD4+ cell count < 200
3
cells/mm ), with pneumococcal 23-polyvalent vaccine booster every 5 years, not to exceed 3 lifetime
doses (Management Guidelines)
[CDC OI]
Influenza virus vaccine, inactivated every fall for women who are not allergic to eggs; the nasal spray influenza
virus vaccine, live should not be administered
Tetanus/diphth/pertuss (Tdap) adult/adol (1 dose) with tetanus toxoid and diphtheria booster (Td) every 10
years; if pregnant, administer Td during second or third trimester or defer until after pregnancy and administer
TdaP
Meningococcal conjugate vaccine (1 or more doses) for individuals at risk for acquiring meningococcal disease
(eg, college students, military recruits, people traveling to endemic areas)
[McLean 2013]
Human papillomavirus vaccine (either bivalent or quadrivalent; 3 doses within 6 months) for women 9-26 years
of age; not recommended during pregnancy
Varicella virus vaccine (2 doses) is recommended for individuals with CD4+ cell count 200 cells/mm and
without a history of chicken pox or evidence of immunity serologically but is contraindicated for individuals with
3
CD4+ cell count < 200 cells/mm and is not recommended during pregnancy
Zoster vaccine live (1 dose) is not routinely recommended but may be given to individuals older than 50 years
3
of age with CD4+ cell count 200 cells/mm and evidence of varicella immunity; a randomized phase II trial in
3
HIV-infected patients on stable antiretroviral therapy with CD4+ cell counts 200 cells/mm demonstrated the
safety and immunogenicity of this vaccine in the indicated patient population (Capsule Summary)
[Benson 2012]
The anthrax vaccine adsorbed and the smallpox vaccine should be avoided for all HIV-infected women.
For additional information from inPractice on immunizations for HIV-infected patients, click here.
For additional information from inPractice on hepatitis virus coinfection, click here.
For additional information from inPractice on other viral infections, click here.
[CDC OI]
Testing may be repeated in HIV-infected patients who had a baseline CD4+ cell count < 200
cells/mm after they achieved a CD4+ cell count 200 cells/mm on antiretroviral therapy.
[CDC OI]
The World
Health Organization clinical guidelines recommend that HIV-infected patients in resource-constrained settings
should be screened for tuberculosis at each clinical interaction by assessing potential symptoms of infection
(coughing, fever, weight loss, and night sweats) and performing diagnostic tests if symptoms are
present (Management Guidelines).
[WHO HIV]
Although traditional screening methods include a tuberculin skin test, screening with newer tests such as
interferon gamma release assays may provide advantages in HIV-infected patients, because results are
obtained immediately and may be more accurate than traditional skin tests; however, these methods are still
controversial.
CD4+ cell count < 200 cells/mm should be rescreened after immune reconstitution. In individuals with a
previous history of a positive tuberculin skin test, a symptom-focused questionnaire should be performed.
Annual chest radiographs for tuberculosis in the absence of symptoms is not indicated.
For additional information from inPractice on tuberculosis screening in HIV-infected patients, click here.
HIV infection may increase the risk of cardiovascular disease, particularly in patients with other modifiable risk
factors; therefore, screening HIV-infected patients for cardiovascular disease risk factors is important.
2007; Freiberg 2013]
[Kaplan
Traditional modifiable risk factors for cardiovascular disease include cigarette smoking,
hypertension, hyperlipidemia, diabetes, and obesity. The most recent guidelines for managing blood
cholesterol identify 4 risk groups of patients for whom moderate- to high-intensity statin therapy is
recommended and advise clinicians to use risk assessment tools to inform statin therapy decisions rather than
target lipoprotein values (Management Guidelines).
[ACC/AHA Cholesterol]
[Currier 2008]
Commonly
used algorithms to predict risk of cardiovascular disease are broadly accurate in HIV-infected populations,
although the Framingham, SCORE, and D:A:D algorithms all underestimate the presence of subclinical
[Serrano-Villar 2012; Chew 2013]
For additional information from inPractice on cardiovascular risk in HIV-infected patients, click here.
The American Cancer Society recommends mammograms and self-breast examinations for women,
regardless of HIV status, beginning at the age of 40 years (Management Guidelines).
[ACS 2003]
A guideline panel
expanded on and developed new recommendations for women at different defined levels of risk. This new
guideline states that screening magnetic resonance imaging is recommended for women with an
approximately 20% to 25% or greater lifetime risk of breast cancer, including women with a strong family
history of breast or ovarian cancer and women who were treated for Hodgkins disease.
[Saslow 2007]
The exact
age at which to start mammograms is controversial. Primary care guidelines from the HIV Medical Association
of the Infectious Diseases Society of America recommend an annual mammography for women aged 50 years
or older, and performing individualized assessment of risk for breast cancer followed by discussion of the risks
and benefits screening mammography with women between 40 and 49 years of age (Management
Guidelines).
[Aberg 2014]
There are no data to suggest that HIV-infected women are at a higher risk for developing
[Grulich 2007]
For additional information from inPractice on breast cancer in HIV-infected women, click here.
Psychosocial stressors should be evaluated on a regular basis in HIV-infected women. A multidisciplinary team
that incorporates social services, mental health, and case management is often required to maintain ongoing
clinical care and medication compliance in this population.
This module includes specific guidance regarding cervical cancer screening and assessment of depression.
Editors in Chief: Joseph J. Eron, Jr., MD; Daniel R. Kuritzkes, MD; Kathleen E. Squires, MD
Contraception options offered to the general population may not be available or appropriate for
women who are HIV positive
Oral Contraceptives
Data on whether the use of hormonal contraceptives effect the progression of HIV disease
are conflicting
[Cejtin 2003; Kilmarx 2000; Richardson 2007; Heffron 2013; Stringer 2009; Phillips 2013]
WHO recommends that women infected with HIV use hormonal contraceptives to prevent
[WHO 2012]
pregnancy
Co-administration of antiretroviral agents may alter the clinical effectiveness of some oral
contraceptives and the pharmacokinetics and efficacy of some antiretrovirals (Table 1)
[Ouellet
1998; Mildvan 2002; Chu 2005; Anderson 2011; El-Ibiary 2008; Crauwels 2009; DHHS Perinatal; Robinson 2012; Tseng 2013; Landolt
2013; ELV/COBI/TDF/FTC PI; Song 2013]
Injectable Contraceptives
DMPA may be associated with an elevated HIV-1 RNA set point when used at the time of
HIV acquisition
[Lavreys 2004]
Data suggesting an association between DMPA use and HIV acquisition or transmission are
controversial, and additional studies are needed
Patients and their partners should be counseled regarding continued use of barrier
contraception (condoms) in addition to other contraceptive choices
All combined hormonal contraceptive methods are listed as Category 1 (no restriction for
use) for women at high risk for HIV or with HIV or AIDS by the CDC Medical Eligibility
Criteria for Contraceptive Use
[CDC MEC]
Efavirenz may decrease etonogestrel levels attained from the etonogestrel implant
[DHHS
The TCu-380A IUD and the levonorgestrel-releasing intrauterine contraceptive system are
acceptable choices for HIV-infected women at low risk for acquiring STDs
[DHHS ART]
Barrier Contraceptives
Spermicides containing nonoxynol 9 topical should not be used for prevention of HIV or
STDs
[WHO 2001]
There are special considerations for reproductive health in HIV-infected women when compared with the
general population. Issues surrounding contraception are multifaceted for HIV-infected women. These women
often feel stigmatized by their diagnosis and, therefore, do not seek appropriate care. Furthermore,
contraception options available to the general population may not be available or appropriate for HIV-positive
women, and there is minimal evidence-based guidance to direct practitioners in this arena.
Oral Contraceptives
The studies that have evaluated whether the use of hormonal contraceptives has any effect on chronic HIV
infection have demonstrated conflicting results. Some studies have not observed an association between
hormonal contraception and HIV disease progression.
In a study of
Zambian women not yet receiving antiretroviral therapy, the use of depomedroxyprogesterone acetate or oral
contraceptives was associated with an accelerated HIV disease progression and death.
[Stringer 2009]
A systematic
review of randomized clinical trials and cohort studies found no evidence that hormonal contraceptives
[Phillips 2013]
should be based on each womans needs rather than possible effects on HIV progression.
2013]
The World Health Organization recommends that women infected with HIV or at high risk of HIV can
[WHO 2012]
The primary concern in HIV-infected women should be focused on effects the antiretroviral agents may have
on the clinical effectiveness of available contraceptive choices (Table 1). Therefore, any nonbarrier
contraceptive should be used in conjunction with a barrier (condom) device, not only for pregnancy prevention
but also to prevent HIV transmission. In addition, contraceptive agents may alter the pharmacokinetics and
efficacy of certain antiretrovirals. Virologic responses to antiretroviral therapy should be monitored closely
when used in combination with nonbarrier contraceptives. Pharmacokinetic interaction should be considered
when combined oral contraceptives and antiretrovirals are used together and certain agents should not be
used concurrently (Table 1).
[Ouellet 1998; Mildvan 2002; Chu 2005;Anderson 2011; El-Ibiary 2008; Crauwels 2009; DHHS Perinatal; Robinson
progesterone and antiretroviral levels when efavirenz and combined oral contraceptives are
coadministered.
[Landolt 2013]
increase the risk of complications including insulin resistance, dyslipidemia, acne, and venous
thrombosis.
[ELV/COBI/TDF/FTC PI]
combination with cobicistat and elvitegravir should be considered, particularly in women who have risk factors
for these complications.
Efavirenz
Etravirine
Nevirapine
Rilpivirine
PIs
Overall Effect or
Recommendation
No effect
Progestin levels markedly decreased
Effectiveness of emergency
contraception may be diminished
Barrier method should be used
No dose adjustment needed
Additional methods recommended;
alternative methods can be considered
No dose adjustment needed
No dose adjustment
Atazanavir
Atazanavir/ritonavir
Darunavir/ritonavir
Fosamprenavir
Fosamprenavir/ritonavir
Indinavir
Lopinavir/ritonavir
Nelfinavir
Ritonavir
Saquinavir/ritonavir
Tipranavir/ritonavir
Integrase Inhibitors
Raltegravir
Cobicistat/elvitegravir/emtricitabine/tenofovir
Dolutegravir
CCR5 Antagonist
Maraviroc
For additional information from inPractice on drugdrug interactions between antiretroviral agents and
hormonal contraceptives, click here.
Injectable Contraceptives
There are no clinically important pharmacokinetic interactions that occur when progestin injectable
contraceptives, such as depot-medroxyprogesterone acetate (DMPA), are used with antiretrovirals; however,
formal studies examining the potential for interaction withritonavir-boosted PIs or cobicistatboosted elvitegravir have not been conducted.
elevated HIV-1 RNA set point when used at the time of HIV acquisition,
[Lavreys 2004]
rapid disease progression. HIV-infected and HIV-uninfected women experience similar adverse effects when
using injectable hormonal contraceptives.
Whether DMPA use is associated with HIV acquisition or transmission is controversial and additional studies
are needed to provide clarity.
prospective cohort,
[Heffron 2012]
[Polis 2013a]
a systematic review
[Noguchi 2014]
acquisition and/or transmission with the use of hormonal contraceptive pills and/or DMPA. However, these
analyses each have limitations and do not provide irrefutable evidence that contraception and HIV
transmission or acquisition are linked. Other publications do not find an association between injectable
contraceptive use and HIV acquisition or transmission.
publication demonstrating an increased risk of HIV acquisition with DMPA, the World Health Organization
issued a statement indicating that it did not find the evidence compelling enough to warrant changing the
current recommendations regarding hormonal contraceptive use.
[WHO 2012]
counseled regarding the continued use of barrier contraception (condoms) in addition to other contraceptive
choices.
[CDC MEC]
use of efavirenz may decrease etonogestrel levels attained from the etonogestrel implant.
Both the copper-containing intrauterine device (TCu-380A IUD) and the levonorgestrel-releasing intrauterine
contraceptive system are acceptable choices for HIV-infected women at low risk for acquiring sexually
transmitted diseases.
[DHHS ART]
Barrier Contraceptives
Barrier methods, such as condoms, should be encouraged in all HIV-infected individuals even when other
forms of contraception are used. Condoms must be used consistently and correctly for effective contraception,
for the prevention of sexually transmitted infections, and for the prevention of HIV transmission. Spermicides
containing nonoxynol 9 topical should not be used for the prevention of HIV or sexually transmitted infection
transmission; products containing nonoxynol 9 topical may increase the risk of HIV transmission.
[WHO 2001]
Sexually active women should receive routine screening for STDs, with increased frequency in the
[Cohen 1997]
following situations:
STD screening should include tests for gonorrhea, chlamydia, trichomonas, syphilis, bacterial
vaginosis, vulvovaginal candidiasis, HSV, and HPV
Women who test positive for gonorrhea, chlamydia, trichomonas, or syphilis should be counseled
regarding safe sexual practices and use of barrier contraception
Gonorrhea, chlamydia, chancroid, and syphilis are reportable STDs in the United States; additional
reporting requirements vary by state
Unprotected sexual intercourse is the most common mode for transmission of HIV and other sexually
transmitted diseases (STDs).
[Cohen 1998]
Women should be counseled routinely to use barrier contraceptive methods to prevent acquisition of an STD,
even if other contraceptive methods are already in use. Routine screening for STDs should occur in sexually
active women and should be performed more often in the following situations:
Gonorrhea/chlamydia
Screen annually in sexually active women or woman with recent change in sexual partner or sexual practice, if
partner has a history of STDs, or if the woman presents with signs or symptoms
Trichomonas vaginalis
Syphilis
Bacterial vaginosis
Vulvovaginal candidiasis
Human papillomavirus
[Atashili 2008]
Women who test positive for gonorrhea, chlamydia, trichomonas, or syphilis should be counseled regarding
safe sexual practices and the use of barrier contraception. Gonorrhea, chlamydia, chancroid, and syphilis are
reportable STDs according to the Centers for Disease Control and Prevention Guidelines (Management
Guidelines).
Incidence of CIN is 4-5 times higher in women infected with HIV than in HIV-negative women
[Wright
In resource-limited countries, cervical cancer screening follows the screen-and-treat model, with
cryosurgery performed at the same visit for women with abnormal findings (Management
Guidelines)
[USNCI Cervical]
In developed countries, women should undergo cervical cancer screening, including HPV testing and
a Pap test, every 6 months in the first year after HIV diagnosis and annually thereafter (Management
Guidelines)
[CDC OI]
Cervical cancer screening should be performed annually regardless of age in women who acquired
HIV infection through sexual intercourse
[CDC OI]
Colposcopy should be offered based on cervical cytology results and HPV DNA (Table 2)
[Cohn
Guidelines on opportunistic infections suggest anal cytologic screening for HIV-infected women,
followed by high-resolution anoscopy in women with abnormal cytologic results
[CDC OI]
Primary care guidelines from HIVMA/IDSA recommend HPV vaccination for all females 9-26 years of
age (Management Guidelines)
[Aberg 2014]
Screening for cervical cancer is important for all HIV-infected women regardless of reproductive status. The
incidence of cervical intraepithelial neoplasia (CIN) among HIV-infected women is 4-5 times higher than in HIVnegative women and is inversely correlated with CD4+ cell counts.
2013]
The risk of human papillomavirus (HPV) infection with the high-risk HPV subtypes (16 and 18) and the
The
use of antiretroviral therapy, however, is associated with regression of cervical dysplasia, which has not been
reported in the absence of antiretroviral therapy.
[Heard 2002]
In resource-limited countries, the rate of cervical cancer is higher than in developed countries, which is
attributed to less widespread screening and a high rate of loss to follow up.
[Belhadj 2013]
screenings in these settings follows the screen-and-treat model. During this single visit, a speculum
examination is performed to visualize the cervix, followed by an application of 3% to 5% acetic acid to inspect
for characteristic acetowhite lesions. Cryosurgery is subsequently performed during that same visit for women
with abnormal examinations (Management Guidelines).
[USNCI Cervical]
In developed countries where providers and advanced testing modalities are widely available, women should
undergo cervical cancer screening that includes HPV testing and a Pap test every 6 months in the first year
after HIV diagnosis and annually thereafter(C) (Management Guidelines).
[CDC OI]
recommendation for HIV-negative women is that a Pap test be performed every 3-5 years,
increased risk in HIV-infected women warrants more frequent screening.
[Massad 2012]
[Saslow 2012]
the
recommend colposcopy at initial HIV diagnosis as HIV-infected women may progress to cervical cancer at a
[Robinson 1997;Holcomb 1998]
faster rate.
performed annually regardless of age in women who were HIV-infected through sexual intercourse (C).
[CDC OI]
Abnormal
Normal
Abnormal
Colposcopy
None indicated; continue
routine screening and
follow-up
Refer for colposcopy
Every 6 mos
Refer for colposcopy
Negative
Positive
Positive
The recommendations for colposcopy in Table 2 are based on studies with a small number of participants.
These studies have included comparisons between HIV-positive and HIV-negative women, assessment of
HIV-positive women at various stages of disease, comparisons between HIV-positive women receiving or not
receiving antiretroviral therapy, and considerations for cost-effectiveness. However, larger studies that
evaluate the long-term outcome in specific subgroups of women are needed.
In addition to cervical cancer, HPV infection can also result in anal intraepithelial neoplasia. Studies have
indicated increased prevalence and diversity of anal HPV infection in HIV-infected women compared with
uninfected women, providing additional support for routing screening for anal cancer.
2012]
Anal Pap tests can be used as preliminary screening to detect anal neoplasia, although poor correlation
[Mallari 2012]
Furthermore, abnormal
cervical cytology can be associated with the presence of abnormal anal cytology (relative risk: 1.7; P = .024),
and the positive predictive value of cervical Pap tests is poor when used to identify women with abnormal anal
cytology.
[Kojic 2011b]
Although there is no consensus for routine screening for anal cancer, the current guidelines
for the prevention and treatment of opportunistic infections suggest anal cytologic screening for HIV-infected
[CDC OI]
women, followed by high-resolution anoscopy in the case of abnormal cytologic results (C).
digital anal examination may also be useful in detecting masses that may be due to anal cancer.
Annual
[CDC OI]
There are currently 2 human papillomavirus vaccines approved by the US Food and Drug Administration for
the prevention of cervical cancer in HIV-negative females aged 9-26 years: a bivalent vaccine (subtypes 16
and 18) and a quadrivalent vaccine (subtypes 16 and 18 plus subtypes 6 and 11, the major causative agents of
genital warts). During vaccine development, clinical trials evaluating both efficacy and immunogenicity were
conducted in HIV-negative females with and without previous exposure to the specific HPV subtypes. Both the
bivalent and quadrivalent human papillomavirus vaccines demonstrated > 93% efficacy in preventing cervical
intraepithelial neoplasia and external genital lesions.
generate robust and durable antibody responses to the HPV subtypes included. It is hoped that a human
papillomavirus vaccine will eliminate cervical cancer, and preliminary data indicate that the vaccine is safe and
immunogenic in HIV-positive women as well.
observed in HIV-infected patients, with the bivalent vaccine eliciting higher titers of antibodies to HPV subtype
18 (similar to what has been observed in uninfected women).
[Toft 2014]
evaluated the overall efficacy of the human papillomavirus vaccine in this patient population. Primary care
guidelines from the HIV Medicine Association of the Infectious Diseases Society of America(Management
Guidelines)
[Aberg 2014]
adolescents 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 (Management Guidelines)
OI]
[CDC
recommend human papillomavirus vaccine for all HIV-infected females 9-26 years of age (C).
Selection of the initial ART regimen for women infected with HIV should be based
on (Management Guidelines)
[DHHS ART]
Comorbidities
Anticipated adherence
Treatment Outcomes
There is some evidence that HIV-infected women are more likely to discontinue treatment
than men
Treatment Complications
[Lucas 1999]
count > 250 cells/mm due to increased risk for severe hepatotoxicity
[Hitti 2004]
Treatment Initiation
The standard US Department of Health and Human Services guidelines for initiation of antiretroviral therapy in
adults should be followed(Management Guidelines).
lower HIV-1 RNA level than men,
[DHHS ART]
[Sterling 2001]
disease progression (B); the strength of this recommendation varies based on pretreatment CD4+ cell count.
In addition to the benefits to the woman herself, antiretroviral therapy also reduces the risk of mother-to-child
HIV transmission (see section on Antiretroviral Therapy in Pregnancy).
Selection of the initial antiretroviral therapy regimen for HIV-infected women should be based on
[DHHS ART]
Childbearing potential: Women wishing to conceive with an HIV-uninfected male partner have 2 primary
options for preventing HIV sexual transmission. The first is artificial insemination. The second option is
treatment with a maximally suppressive antiretroviral regimen. Women of childbearing potential should be
counseled on the potential risk associated with first trimester exposure toefavirenz; this drug may not be the
optimal choice for inclusion in an initial antiretroviral regimen in women of childbearing age who do not use
adequate contraception. Potential interactions between hormonal contraceptives and antiretroviral agents
should also be discussed and additional or alternative contraception used when appropriate. Safety and
pharmacology of newer agents, such asrilpivirine, dolutegravir,
and cobicistat/elvitegravir/emtricitabine/tenofovir, have not been evaluated in pregnancy. Of note, the most
vulnerable period for organogenesis is very early in gestation, often before pregnancy is recognized.
Serodiscordant couples: For serodiscordant couples wanting to conceive, use of antiretroviral therapy is
recommended for the HIV-infected partner. Conception should not be attempted until maximal viral
suppression is achieved. Pre-exposure prophylaxis (PrEP) for an HIV-uninfected partner can be offered as an
option for safer conception; however, the added benefit beyond viral suppression (and treatment of sexually
transmitted diseases) in the HIV-infected partner has been questioned.
[Hoffman 2013]
all available alternatives and lab testing for HIV infection, hepatitis B virus infection, and baseline renal function
prior to initiation ofemtricitabine/tenofovir as well as screening for sexually transmitted diseases. Adverse event
monitoring and HIV testing should be conducted during PrEP, and individuals should be continually aware of
the symptoms and potential for acute HIV infection. If HIV infection is identified, PrEP should be stopped
immediately and strategies to prevent perinatal transmission should be initiated if pregnancy has occurred; if
pregnancy has not occurred, conception attempts should be halted until further guidance from an HIV
specialist is obtained.
[DHHS Perinatal]
specialist.
Risk for specific complications: Antiretroviral-naive women with CD4+ cell counts > 250 cells/mm or
elevated baseline transaminase levels are at heightened risk of liver toxicity when taking nevirapine, and
therefore, a risk-benefit analysis should be conducted when considering nevirapine in this group of women.
Regardless of the regimen selected, women should be counseled on signs of lactic acidosis and evaluated for
this potential complication of antiretroviral therapy.
Other medical conditions: Individuals with elevated cardiovascular disease risk, for example, might wish to
avoid agents associated with dyslipidemia; individuals with osteopenia may wish to avoid agents associated
with greater reductions in bone mineral density.
Anticipated compliance: For individuals at increased risk of poor adherence, simpler antiretroviral therapy
regimens and those with few known adverse effects may be most appropriate. A discussion of how treatment
will be incorporated into a patients lifestyle should also be conducted, and any adverse events should be
proactively managed.
Additional factors to consider include potential drugdrug interactions with hormonal contraceptives, the
potential for depressed immunologic responses and increased comorbidities in older women, and drug-specific
data on effectiveness and adverse events in women.
[Greig 2014]
numbers of HIV-infected women with clinical indications for treatment in the United States are not receiving
antiretroviral therapy. An analysis of factors associated with antiretroviral therapy use among 1354 HIVinfected women in the WIHS database who were clinically eligible for antiretroviral therapy in 2005 found that
[Lillie-Blanton 2010]
insurance were each associated with reduced likelihood of antiretroviral therapy use in an adjusted analysis. Of
note, the results showed that women with publicly funded health insurance were more likely to receive
antiretroviral therapy than women with private health insurance. The reasons for this finding are not known;
potential causes include differences between public and private health programs regarding coverage levels,
support services provided, or HIV experience of participating physicians. These factors remain to be
investigated.
For additional information from inPractice on the timing and choice of first-line therapy in HIV, please click
here.
Treatment Outcomes
Outcomes from large treatment studies in both antiretroviral-naive and antiretroviral-experienced patients have
generally demonstrated nearly equivalent responses between men and women.
2003; Prins 2005; Collazos 2007]
However, some retrospective cohort studies in the United States and Canada have
found that women are statistically less likely than men to achieve virologic suppression after initiating
antiretroviral therapy.
In recent years, the US Food and Drug Administration has required the development of postmarket analyses to
generate additional data on the efficacy of newly approved agents in populations underrepresented in pivotal
clinical trials. GRACE was the first study designed with the primary objective to compare treatment efficacy by
sex and race.
[Currier 2010]
This study demonstrated that there were no differences in virologic responses between
women and men receiving a darunavir/ritonavir-based regimen. Although efficacy did not vary, women were
more likely to discontinue therapy for reasons other than virologic failure despite the absence of statistically
significant sex-based differences in adverse events. The REALMRK study was conducted to evaluate efficacy
[Squires 2013]
demonstrated that virologic response rates were similarly high among women and men and among black and
nonblack patients. Similar to the GRACE trial, discontinuation rates were higher for women compared with
men.
[Hodder 2012]
THRIVE,
[Hodder 2012]
and ARTEMIS
[Mills 2009]
based differences in treatment outcomes. However, these studies were not designed to detect sex differences.
The US Food and Drug Administration has completed a treatment efficacy meta-analysis that demonstrated
equivalent efficacy of antiretroviral therapy between men and women.
[Soon 2012]
In addition, virologic
suppression in women does not seem to vary by age. In an observational cohort analysis, the rate of virologic
response (HIV-1 RNA < 400 copies/mL) following 6 months of antiretroviral therapy was similar between men
and women, regardless of age category: 66% for men vs 67% for women younger than 50 years of age and
73% for men vs 78% for women 50 years of age or older (P = .68 for men vs women).
[Patterson 2007]
Immunologic
responses following antiretroviral therapy were also not affected by age or sex (P = .29). Furthermore, similar
responses were demonstrated in a clinical trials cohort of premenopausal and postmenopausal women.
[Patterson
2009]
Currently, there are 2 ongoing phase IIIb trials designed specifically to evaluate outcomes in treatment-naive
HIV-infected women. WAVES is a double-blind study comparing fixeddose cobicistat/elvitegravir/emtricitabine/tenofovir with ritonavirboosted atazanavir plusemtricitabine/tenofovir (Clinical Trial: NCT01705574), whereas ARIA is an open-label
investigation comparing fixed-dosedolutegravir/abacavir/lamivudine withritonavirboosted atazanavir plus emtricitabine/tenofovir (Clinical Trial: NCT01910402).
Treatment Complications
Despite similar efficacy profiles between men and women receiving antiretroviral therapy, women have a
higher risk for experiencing specific treatment-related complications including, most notably, rash and lactic
[Prins 2005]
acidosis. Overall, there are increased antiretroviral therapyassociated adverse events in women,
and
in some studies, HIV-infected women are more likely to modify or discontinue antiretroviral therapy because of
[Lucas 1999]
adverse events.
For example, women experienced more nausea and less diarrhea as compared with
[Molina 2010]
[Mills 2009]
men in both the CASTLE
and ARTEMIS
trials. These findings suggest that any subtle
differences in treatment outcomes may be related more to reduced treatment tolerability that is not captured in
the traditional grading categories. Studies are in progress to more carefully describe reasons why women are
[Currier
more likely than men to discontinue antiretroviral therapy in the absence of severe adverse events.
2000; Currier 2010]
Adverse events associated with NRTIs are more common in women and include lactic
acidosis[Brinkman 1999] hepatotoxicity, andzidovudine-associated complications (anemia). For NNRTIs,
associated adverse events more prevalent in women include rash[ref: BersoffMatcha 2001; Mazhude 2002] and
hepatotoxicity.[Sanne 2005] The initiation of a nevirapine-containing regimen should be avoided in
women with a CD4+ cell count > 250 cells/mm3 (and men with a CD4+ cell count > 400 cells/mm3)
as the risk for severe hepatotoxicity is increased.[Hitti 2004] Adverse events associated with PIs are
also more prevalent in women and include ritonavir intolerance. Data from a pharmacokinetic
study designed to compare sex differences showed that ritonavir levels were higher in women
compared with men; however, it is not clear whether these higher levels correlate to intolerance
in prospective studies.[Umeh 2011]
Two reports from ACTG studies suggest clinically important sex-based differences in the pharmacology of
antiretroviral drug combinations. A secondary objective in ACTG study A5202 was to evaluate the association
of sex on primary study outcomes of time to virologic failure, safety, and tolerability.
The
[Smith 2014]
clinical implications for women of childbearing potential who are more likely to be prescribed protease inhibitors
as a result of efavirenz pregnancy class D categorization. There was also the suggestion that male subjects
drove the previously reported emtricitabine/tenofovir superiority over abacavir/lamivudinein subjects with higher
HIV-1 RNA levels, and abacavir/lamivudine may have equivalent efficacy in women. Yet female participants
receivingabacavir/lamivudine were more likely to have grade 3/4 safety events than males.
The interim
[Campbell 2008]
[Campbell 2012]
responses to specific antiretroviral therapy regimens based on patient sex. The PEARLS study
compared lamivudine/zidovudine plus efavirenz vsemtricitabine/tenofovir plus efavirenz vs didanosine plus emt
ricitabine plus atazanavir in resource-limited settings. The regimen containing unboosted atazanavir was found
to have higher rates of treatment failure in a review by the data and safety monitoring board. In contrast to
A5202, women randomized to unboosted atazanavir were not found to have a higher rate of treatment failure
compared with men; instead, male sex was identified as a risk factor for treatment failure.
2012]
The difference in efficacy may be due to the decreased clearance of atazanavir (12 L/hr in women vs 14
L/hr in men), increased atazanavir exposure (34 mg*hr/L in women vs 30 mg*hr/L in men), and increased
maximum concentration of atazanavir (182 ng/mL in women vs 94 ng/mL in men) noted in the population
pharmacokinetic analysis from PEARLS
2008]
[Andrade 2011]
These recent analyses lend further support to the need for additional women-focused treatment studies.
HIV-infected women develop different anthropometric changes after the initiation of antiretroviral therapy
compared with age-matched HIV-negative women. The FRAM study demonstrated that significantly more HIVinfected women compared with HIV-negative age-matched women experienced peripheral lipoatrophy (fat loss
in arms, cheeks, face, buttocks, and legs) (28% vs 4%, respectively; P < .001) (Capsule Summary).
[FRAM 2006]
In
addition, significantly fewer HIV-infected women experienced peripheral lipohypertrophy compared with
uninfected controls (35% vs 62%, respectively; P < .001). Central fat gain or lipohypertrophy was common in
both HIV-infected and control women, which is important because studies without control groups attribute all of
the central fat gain observed to HIV infection. Increased levels of serum triglycerides, leptin, and low density
lipoprotein cholesterol are also found in HIV-infected women.
In general, however,
women are less likely to develop triglyceride elevations while receiving antiretroviral therapy. In the general
HIV population, insulin resistance has a very high prevalence ranging from 35% to 50%. There are no specific
studies demonstrating that women are at higher risk for insulin resistance. However, individuals who are
receiving PI therapy or who have developed lipodystrophy syndrome are thought to be at higher risk for insulin
resistance.
[Dube 2008]
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[Cook 2006]
concurrently
Within the general population and among persons infected with HIV, women have a higher rate of depression
than men. Approximately 50% of HIV-infected womennearly double that of HIV-infected menhave
characteristics consistent with depressive symptoms or disorders.
In addition, 1 in 5 HIV-
infected women meet the classification for major depressive disorders compared with 1 in 20 HIV-negative
women.
[Morrison 2002]
etiologies of the depression diagnosis often require formal psychiatric or mental health counseling to overcome
the disorder. Given the frequency of depression in this population, depression screening should be
incorporated into routine clinical care. Screening tools such as the Edinburgh Postnatal Depression Scale may
be useful in detecting antenatal depression in HIV-infected women.
[Rochat 2013]
Depression is sometimes
associated with domestic violence and therefore screening for past or ongoing intimate partner violence may
also be clinically relevant.
Depression may
or may not
affect immunologic
recovery following initiation of antiretroviral therapy. Individuals with depression may have a diminished
[Anastos 2000]
virologic response
[Pence 2007]
Access to
pharmacologic and psychiatric therapy increases the use of antiretroviral therapy among HIV-infected women
with depression.
[Cook 2006]
[Li 2014]
intimate partner violence have lower rates of adherence to antiretroviral treatment, particularly those who score
lower on resilience assessment tests.
[Dale 2014]
violence in all women at entry to care, when adherence patterns change, and if concern for depression
emerges. Women should be made aware and linked to appropriate support services.
Women with depression have increased rates of all-cause and AIDS-related mortality and new AIDS-defining
illnesses.
[Cook 2002b]
substance abuse.
Untreated depression may result in higher rates of sexually transmitted infections and
[Fialho 2013]
disorders appear to have similar responses to antiretroviral therapy, supporting the concurrent treatment of HIV
and depression.
Neuropsychiatric complications related to the use of antiretroviral medications, ranging from vestibular
symptoms and sleep disorders to frank psychosis, have been documented in several case reports of various
complications with zidovudine,
2004]
and nevirapine,
of efavirenz.
[Wise 2002]
abacavir,
history of mental health problems may be at an increased risk of developing such complications
of efavirenz use; however, the studies are contradictory and inconclusive. Regardless, although many
providers will be hesitant to use efavirenz in women with a diagnosis of depression, preexisting depression is
not a contraindication for efavirenz use. If used, vigilant observation for the development of psychiatric
problems when initiating therapy with efavirenz-containing regimens is advised in women with a history of
mental health problems.
Efficacy trials of antidepressant use in HIV-infected women are lacking. In a study that included mostly HIVinfected men (83%), depressed patients compliant with selective serotonin reuptake inhibitor (SSRI) use
adhered to their antiretroviral therapy regimens and achieved viral control that was statistically similar to
nondepressed HIV-infected patients receiving antiretroviral therapy. Furthermore, depressed patients
compliant with SSRI treatment had statistically significantly greater immunologic responses when compared
with depressed patients who were noncompliant with their SSRI regimen.
[Horberg 2008]
antidepressant agent in women receiving antiretroviral therapy, care must be taken to make sure there are no
metabolic interactions that may increase adverse effects or diminish the efficacy of either agent.
Although depression is a common mental health issue in HIV-infected women, there is a growing body of
evidence demonstrating the efficacy of antiretroviral therapy in improving depressive symptoms.
2000]
Moreover, treating depression improves HIV outcomes. Therefore, positive mental health and HIV
outcomes can be achieved when the 2 diagnoses are addressed concurrently. Ongoing screening for
depression should be used in the clinical setting with referral for appropriate mental health intervention when
indicated.
For additional information from inPractice on psychiatric disorders in HIV-infected patients, click here.
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Barrier Contraceptives
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Treatment Complications
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Mode of Delivery
Postpartum Management
Age of Menopause
Symptoms of Menopause
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[DHHS Perinatal]
[CDC
Testing 2006]
[DHHS Perinatal]
Immunizations
Intrapartum Management
[DHHS
Perinatal]
[DHHS Perinatal]
Mode of Delivery
[DHHS Perinatal]
delivery (Management
Guidelines)
[DHHS Perinatal]
oral zidovudine
Methylergonovine should be
avoided in women receiving PIs
or efavirenz
delivery
Postpartum Management
[DHHS
Perinatal]
[DHHS Perinatal]
During the past 25 years, guidelines for the treatment of HIV-infected pregnant women and prevention of
perinatal transmission have evolved considerably. The current recommendations focus on ensuring use
of antiretroviral therapy by known HIV-infected pregnant women, regardless of maternal health needs, to
reduce the risk of mother-to-child transmission; identifying HIV infection in pregnant women with previously
undiagnosed or newly acquired HIV infections; preventing HIV transmission to infants through the use of
chemoprophylaxis antiretroviral therapy; and avoiding breastfeeding. These recommendations have resulted in
a significant decrease in perinatal transmission ratesto less than 2%in the United States and the United
Kingdom.
[Townsend 2008]
the most common circumstances that occur in the care of HIV-infected pregnant women (Management
Guidelines).
[DHHS Perinatal]
recommended in areas of high HIV prevalence, women at high risk for HIV infection, or women with symptoms
of acute HIV infection.
incidence rate of 16.75 per 1000 person-years during pregnancy in a group of women in Swaziland who were
HIV negative at initial testing. In total, 4.4% of women who were HIV negative at study entry were HIV positive
at the time of delivery.
[Kieffer 2011]
Other studies have shown higher rates of HIV acquisition in pregnant women
(2.3 per 1000 person-years) when compared with nonpregnant (1.1 per 1000 person-years) or lactating (1.3
per 1000 person-years) women.
[Gray 2005]
These data suggest that pregnant women may be at increased risk for
HIV transmission and that repeat testing is warranted in sexually active women during pregnancy.
Women who present to labor and delivery with unknown HIV status or who are at risk for HIV should undergo
rapid testing. Those with a positive rapid test should receive intravenous zidovudine (A). Initiation
of zidovudine should not be delayed for testing confirmation.
Cigarette smoking
Therefore, counseling to avoid tobacco and illicit drug use, encouraging the use of condoms during sexual
intercourse, and screening for genital tract infections should be integrated into care.
Biological factors associated with perinatal transmission of HIV are primarily determined by maternal health.
These factors include:
Antiretroviral resistance
Initial management should also include screening for hepatitis B virus, hepatitis C virus, and tuberculosis. A
thorough history of adverse effects during previous antiretroviral regimens should also be gathered.
Decisions regarding which antiretroviral combinations are most effective in pregnancy are complex and should
be made in consultation with a provider who has an understanding of these complexities (Table 3).
Perinatal; DHHS ARV Safety]
[DHHS
through lowering plasma HIV-1 RNA but also due to pre-exposure prophylaxis (PrEP) for the infant. The
mechanism by which infant PrEP is effective is through antiretroviral agents crossing the placenta, resulting in
adequate systemic concentrations in the infant. This is especially important at the time of delivery when the
infant is exposed to maternal blood and genital tract secretions. Because transmission can occur in women at
any plasma HIV-1 RNA level, including those with undetectable plasma HIV-1 RNA, all HIV-infected pregnant
women should be offered antiretroviral therapy. One or more NRTIs with high levels of transplacental passage
should be used. Antiretroviral therapy should be initiated as soon as possible in pregnant women who have
indications for antiretroviral therapy. Initiation of antiretroviral therapy can be delayed until after the first
trimester for women receiving antiretroviral therapy for fetal protection, but earlier initiation is more effective in
preventing transmission. Data from a recent study involving 806 infants found that infants exposed to
antiretroviral therapy during the first trimester of pregnancy did not have an increased risk of birth defects
compared with unexposed infants (odds ratio: 1.07; 95% CI: 0.50-2.31).
[Phiri 2014]
viremic during pregnancy or are diagnosed with HIV late in pregnancy, a raltegravir-containing regimen can
rapidly decrease viral load.
antiretroviral therapy.
[Westling 2012]
[Rachas 2013]
The recommendations for initiation of antiretroviral therapy for maternal health are similar between pregnant
and nonpregnant HIV-infected women; however, additional factors specific to pregnancy must be considered.
an increased risk.
[Brogly 2010]
[DHHS Perinatal]
Typically, the most appropriate course of action for HIVinfected women who are virologically suppressed on
antiretroviral therapy and subsequently become pregnant is
to continue the current antiretroviral regimen, regardless of
agent(s) because of the (small) risk of virologic breakthrough
that may accompany any regimen modification.
[Powis 2011]
[DHHS ART]
NRTI
Preferred
Antiretroviral Therapy
Abacavir/lamivudine
Emtricitabine/tenofovir ortenofovir/lamiv
udine
Lamivudine/zidovudine
Not
recommend
ed
Abacavir/lamivudine/zidovudine
Didanosine
Pregnan
cy Drug
Class
Additional
Considerations
C/C
Abacavir should
not be used in
patients who test
positive for HLAB*5701.
QD administration.
Potential renal
toxicity
with tenofovir; use
with caution in
patients with renal
insufficiency.
NRTI combination
that has most
experience in
pregnancy.
Disadvantages
include BID
dosing and
potential for
increased
hematologic
toxicity.
Inferior virologic
efficacy.
B/B or
B/C
C/C
C/C/C
Not recommended
because of toxicity.
NNRTI
Preferred
Stavudine
Not recommended
because of toxicity.
Efavirenz
Alternative
Nevirapine
Insufficient
data
Rilpivirine
Preferred in
women who
require
concomitant use of
drugs that interact
with PIs.
Use with caution in
women who are
starting ART with
baseline CD4+ cell
count > 250
cells/mm3 due to
hepatotoxicity. Use
with caution in
combination
with abacavirbecau
se both agents can
cause
hypersensitivity
reaction within
first few wks of
treatment.
Limited data. Not
recommended with
baseline HIV-1
RNA > 100,000
Not
recommend
ed
PI
Preferred
Etravirine
Atazanavir/ritonavir
copies/mL or
CD4+ cell count <
200 cells/mm3. Do
not use in
combination with
proton pump
inhibitor.
Not recommended
in ART-naive
patients.
B/B
Should be given as
boosted regimen.
QD administration.
Some experts
recommend
increased dosing
during the second
and third
trimesters.
The package insert
recommends
increased dosing
only for:
ART-experienced
pregnant women
in the second
and third
trimesters also
receiving
either tenofovir or
an H2-receptor
antagonist (not
both), or
ART-naive
pregnant women
also
receivingefaviren
z.
Should not be used
in ARTexperienced
Lopinavir/ritonavir
Ritonavir
Alternative
Darunavir/ritonavir
C/B
C/B
pregnant patients
receiving
both tenofovir and
H2-receptor
agonists or in
antiretroviralexperienced
patients also
taking efavirenz or
proton-pump
inhibitors.
Avoid QD dosing
during pregnancy.
Unclear if dose
increase to 3
tablets BID in
second and third
trimester is
necessary in ARTnaive patients.[Patterson
2013]
Closely monitor
virologic response
and lopinavir level
s if standard dosing
used in PIexperienced
patients.
Should only be
used in
combination with
second PI as lowdose ritonavir boo
st to increase
levels of second
PI.
Limited data.[Zorrilla
2014]
May be
considered when
preferred agents
cannot be used.
Must boost with
low-dose ritonavir.
Not
recommend
ed
Insufficient
data
Entry
inhibitors
Insufficient
data
Not
recommend
ed
Integrase
Saquinavir/ritonavir
B/B
Indinavir/ritonavir
C/B
Nelfinavir
Tipranavir
Fosamprenavir/ritonavir
C/B
Limited
pharmacokinetic
data
on saquinavir in
pregnancy.
Baseline
electrocardiogram
recommended
before initiating
treatment based on
potential for PR
and QT
prolongation;
contraindicated
with preexisting
cardiac conduction
system disease.
Large pill burden.
Not recommended
because of BID
dosing, pill burden,
and potential for
renal stones,
hyperbilirubinemia
.
Previous reports of
ethyl methane
sulfonate
contamination
have been
resolved. Inferior
virologic efficacy.
Not recommended
in ART-naive
patients.
Limited data.
Maraviroc
Limited data.
Enfuvirtide
Not recommended
in ART-naive
patients.
inhibitors
Alternative
Insufficient
data
Raltegravir
Dolutegravir
Cobicistat/elvitegravir/emtricitabine/teno
fovir
B
B
[DHHS Perinatal]
Ultrasound
Laboratory monitoring
Renal toxicity
Hyperglycemia
Metabolic alterations are common during pregnancy and can be complicated by ART. Clinicians should closely
monitor patients during pregnancy, tailoring treatment and recommending lifestyle alterations to manage
metabolic conditions that can affect both the mother and infant.
[Guaraldi 2014]
For additional information from inPractice on laboratory assays used in patient monitoring, click here.
Immunizations
The immunization history of HIV-infected pregnant women should be reviewed at the initial prenatal visit.
Women should follow the same vaccination schedule as nonpregnant HIV-infected individuals with special
attention given to make sure HIV-infected women are vaccinated against hepatitis A and B (if antibodies are
not present) and influenza. Because HIV-infected persons and pregnant women are each individually at
increased risk for influenza-related complications, HIV-infected pregnant women should be strongly
encouraged to receive the [drug: influenza virus vaccine, inactivated].
Intrapartum Management
The PACTG 076 trial demonstrated that the use of zidovudine (antepartum, intravenous zidovudine during
delivery and in the infant) decreased perinatal transmission by 67.5%.
[Connor 1994]
As a result,
intravenous zidovudine during labor and delivery (regardless of mode of delivery) is still highly
recommended for women with HIV-1 RNA > 1000 copies/mL or unknown HIV-1 RNA levels unless there is
evidence of resistance or toxicity (A) (Management Guidelines).
[DHHS Perinatal]
suppressed consistently during late pregnancy and for whom there are no adherence concerns, current
antiretroviral therapy does not require the addition of intravenous zidovudine. However, every effort should be
made to administer zidovudine in appropriate patients. Neonatal zidovudineprophylaxis for 6 weeks is also
recommended.
[DHHS Perinatal]
Mode of Delivery
Women whose HIV-1 RNA remains > 1000 copies/mL should be recommended to undergo Cesarean section,
whereas it is unclear if Cesarean section delivery confers added benefit in women receiving antiretroviral
therapy with plasma HIV-1 RNA 1000 copies/mL(Management Guidelines).
[DHHS Perinatal]
RNA > 1000 copies/mL, a Cesarean section should be scheduled at 38 weeks of gestation, if possible.
Intravenous zidovudine should be used, with infusion initiated 3 hours before the scheduled Cesarean section
delivery (2 mg/kg over 1-hour loading dose, then 1 mg/kg/hour continuous infusion until delivery, ie, umbilical
cord ligated).
In women whose HIV-1 RNA is 1000 copies/mL, Cesarean section delivery required for standard obstetric
indications should be performed at 39 weeks of gestation. Invasive fetal monitoring or operative delivery with
vacuum devices or forceps should be avoided in HIV-infected women, as these may increase risk of
transmission.
and women should be moved toward Cesarean section delivery if labor does not progress 4 hours after
membranes have ruptured (C). Intravenous infusion with zidovudine should be initiated at the onset of labor,
using the dosing schedule outlined for Cesarean section.
Women who present to labor and delivery who are not receiving antiretroviral therapy:
Women who have positive rapid HIV testing at labor and delivery:
Postpartum Management
Current recommendations highlight the need for antiretroviral therapy for all HIV-infected patients, because
untreated HIV infection or uncontrolled viremia may be associated with adverse outcomes including increased
risk of cardiovascular disease, liver disease, and neurologic complications (Management Guidelines).
ART]
[DHHS
Moreover, the SMART study demonstrated that among patients with a prior CD4+ cell count < 350
3
cells/mm , interrupting antiretroviral therapy is associated with an increased risk of immunologic impairment
resulting in risk of opportunistic disease or death from any causeas well as a higher risk of AIDS-defining
[El-Sadr 2006;Lundgren 2008; Silverberg 2007]
malignancies.
antiretroviral therapy in the postpartum period. However, decisions regarding the continuation of antiretroviral
therapy postpartum should involve consultation between the woman and her HIV provider, preferably before
delivery, and with the following considerations in mind (Management Guidelines)
[DHHS Perinatal]
Breastfeeding is not recommended in any HIV-infected women with access to clean water and formula,
regardless of HIV-1 RNA level, because of the increased risk of HIV transmission (C).
[DHHS Perinatal]
However, in
settings that lack such access and where breastfeeding is required for infant health, data from the PROMOTE
study comparing efavirenz plus lamivudine/zidovudine withlopinavir/ritonavir plus lamivudine/zidovudine in 389
pregnant women in rural Uganda are informative. Antiretroviral therapy was initiated at 12-28 weeks of
gestation and continued to 1 year or throughout breastfeeding (women were counseled to breastfeed for 1
year). A recent subanalysis of the study revealed a very low HIV transmission rate of 0.5% among live-born
infants, including only 1 case of transmission during breastfeeding, which occurred in the lopinavir/ritonavircontaining arm (Capsule Summary).
[Cohan 2014]
Virologic suppression rates were high at > 85% at all time points
and in both treatment arms throughout the trial. The randomized, controlled BAN trial conducted in Lilongwe,
Malawi also provides informative data on the role of antiretroviral therapy in preventing HIV transmission during
breastfeeding. In this study, 2369 HIV-infected breastfeeding mother-infant pairs (mothers required to have
3
CD4+ cell count 250 cells/mm ) were randomized to 1 of the following 28-week regimens: maternal triple
antiretroviral therapy (n = 849); daily infant nevirapine (n = 852); or no extended postnatal antiretroviral
regimen (n = 668).
[Chasela 2010]
The estimated HIV transmission risk between postnatal Weeks 2-28 was
significantly higher, at 5.7%, for infants in the group that received no extended postnatal antiretroviral therapy
than for infants in the maternal-regimen group (2.9%; P = .009) or for those in the infant-regimen group
(1.7%; P < .001). The results demonstrated that either maternal triple antiretroviral therapy or
infant nevirapine was effective at reducing the risk of HIV transmission during breastfeeding.
Premastication of food has also been associated with HIV transmission and should be avoided. Women should
be counseled regarding contraceptive choices. A dual protection strategy may be considered to protect against
both unintended pregnancy and HIV transmission in the postpartum period.
Mode of Delivery
SUMMARY
Women whose HIV-1 RNA remains > 1000 copies/mL near the time of delivery should be advised to
undergo Cesarean section(Management Guidelines)
[DHHS Perinatal]
It is unclear if scheduled Cesarean section delivery would provide additional reduction in perinatal
transmission risk for women receiving antiretroviral therapy with HIV-1 RNA 1000 copies/mL
Invasive fetal monitoring, operative delivery with vacuum devices or forceps, and artificial or
prolonged rupture of membranes should be avoided in HIV-infected women
Women whose HIV-1 RNA remains > 1000 copies/mL should be recommended to undergo Cesarean section,
whereas it is unclear if Cesarean section delivery confers added benefit in women receiving antiretroviral
therapy with plasma HIV-1 RNA 1000 copies/mL(Management Guidelines).
[DHHS Perinatal]
RNA > 1000 copies/mL, a Cesarean section should be scheduled at 38 weeks of gestation, if possible.
Intravenous zidovudine should be used, with infusion initiated 3 hours before the scheduled Cesarean section
delivery (2 mg/kg over 1-hour loading dose, then 1 mg/kg/hour continuous infusion until delivery, ie, umbilical
cord ligated).
In women whose HIV-1 RNA is 1000 copies/mL, Cesarean section delivery required for standard obstetric
indications should be performed at 39 weeks of gestation. Invasive fetal monitoring or operative delivery with
vacuum devices or forceps should be avoided in HIV-infected women, as these may increase risk of
transmission.
and women should be moved toward Cesarean section delivery if labor does not progress 4 hours after
membranes have ruptured (C). Intravenous infusion with zidovudine should be initiated at the onset of labor,
using the dosing schedule outlined for Cesarean section.
Women should continue their oral ART regimen as prescribed before and during labor and
delivery (Management Guidelines)
[DHHS Perinatal]
HIV-infected women who present to labor and delivery who are not receiving ART, or women who
[DHHS Perinatal]
have a positive rapid HIV test at labor and delivery, should initiate IV zidovudine as soon as possible
and undergo Cesarean section delivery
[DHHS Perinatal]
Women should continue their oral antiretroviral therapy regimen as prescribed before and during the
[DHHS Perinatal]
Women who present to labor and delivery who are not receiving antiretroviral therapy:
Intravenous zidovudine infusion (2 mg/kg loading dose followed by 1 mg/kg/hour continuous infusion) should
be initiated as soon as possible
Infants should receive zidovudine for 6 weeks unless testing confirms positivity
Infants of mothers with suboptimal viral suppression may also receive a full antiretroviral therapy regimen
Women who have positive rapid HIV testing at labor and delivery:
Intravenous zidovudine infusion (2 mg/kg loading dose followed by 1 mg/kg/hour continuous infusion) should
be initiated as soon as possible
Infants should receive zidovudine until the mothers HIV status is confirmed and infant test results are
confirmed
Postpartum Management
SUMMARY
[DHHS Perinatal]
Breastfeeding is currently not recommended in any HIV-infected women with access to clean water
and formula, regardless of HIV-1 RNA level
[DHHS Perinatal]
Current recommendations highlight the need for antiretroviral therapy for all HIV-infected patients, because
untreated HIV infection or uncontrolled viremia may be associated with adverse outcomes including increased
risk of cardiovascular disease, liver disease, and neurologic complications (Management Guidelines).
ART]
[DHHS
Moreover, the SMART study demonstrated that among patients with a prior CD4+ cell count < 350
3
cells/mm , interrupting antiretroviral therapy is associated with an increased risk of immunologic impairment
resulting in risk of opportunistic disease or death from any causeas well as a higher risk of AIDS-defining
[El-Sadr 2006;Lundgren 2008; Silverberg 2007]
malignancies.
antiretroviral therapy in the postpartum period. However, decisions regarding the continuation of antiretroviral
therapy postpartum should involve consultation between the woman and her HIV provider, preferably before
delivery, and with the following considerations in mind (Management Guidelines)
[DHHS Perinatal]
The option of continuing antiretroviral therapy in women who initiated antiretroviral therapy for fetal protection
should be recommended unless a contraindication exists; however, antiretroviral therapy may be simplified to
increase adherence
Women who received an NNRTI (nevirapine or efavirenz) and elect to discontinue antiretroviral therapy after
delivery should discontinue the NNRTI while continuing the other antiretroviral agents (NRTIs) for an additional
week to decrease the risk of NNRTI resistance. Alternatively, a PI may be substituted for the NNRTI for 7 days
and then all antiretroviral therapy discontinued simultaneously. Women whose antepartum regimen did not
include an NNRTI and who plan to discontinue antiretroviral therapy after delivery can stop all drugs
simultaneously
Adherence to antiretroviral therapy should be reinforced postpartum as it often decreases during this period;
clinicians should evaluate patients for issues that may reduce adherence (eg, depression or drug and alcohol
use)
Breastfeeding is not recommended in any HIV-infected women with access to clean water and formula,
regardless of HIV-1 RNA level, because of the increased risk of HIV transmission (C).
[DHHS Perinatal]
However, in
settings that lack such access and where breastfeeding is required for infant health, data from the PROMOTE
study comparing efavirenz plus lamivudine/zidovudine withlopinavir/ritonavir plus lamivudine/zidovudine in 389
pregnant women in rural Uganda are informative. Antiretroviral therapy was initiated at 12-28 weeks of
gestation and continued to 1 year or throughout breastfeeding (women were counseled to breastfeed for 1
year). A recent subanalysis of the study revealed a very low HIV transmission rate of 0.5% among live-born
infants, including only 1 case of transmission during breastfeeding, which occurred in the lopinavir/ritonavircontaining arm (Capsule Summary).
[Cohan 2014]
Virologic suppression rates were high at > 85% at all time points
and in both treatment arms throughout the trial. The randomized, controlled BAN trial conducted in Lilongwe,
Malawi also provides informative data on the role of antiretroviral therapy in preventing HIV transmission during
breastfeeding. In this study, 2369 HIV-infected breastfeeding mother-infant pairs (mothers required to have
3
CD4+ cell count 250 cells/mm ) were randomized to 1 of the following 28-week regimens: maternal triple
antiretroviral therapy (n = 849); daily infant nevirapine (n = 852); or no extended postnatal antiretroviral
regimen (n = 668).
[Chasela 2010]
The estimated HIV transmission risk between postnatal Weeks 2-28 was
significantly higher, at 5.7%, for infants in the group that received no extended postnatal antiretroviral therapy
than for infants in the maternal-regimen group (2.9%; P = .009) or for those in the infant-regimen group
(1.7%; P < .001). The results demonstrated that either maternal triple antiretroviral therapy or
infant nevirapine was effective at reducing the risk of HIV transmission during breastfeeding.
Premastication of food has also been associated with HIV transmission and should be avoided. Women should
be counseled regarding contraceptive choices. A dual protection strategy may be considered to protect against
both unintended pregnancy and HIV transmission in the postpartum period.
HIV-infected women may be at increased risk for conditions linked with estrogen deficiency
[Kanapathipillai
Age of Menopause
Lower CD4+ cell count, low physical activity, and injection drug use may be associated with
earlier menopause in HIV-infected women
[Schoenbaum 2005]
Symptoms of Menopause
Current evidence supports the use of hormone replacement therapy for relief of vasomotor
symptoms associated with menopause, although data in HIV-infected women are lacking
Potential drug interactions between hormone replacement therapy and ART are not known
Postmenopausal women should undergo routine health screening, including annual Pap
smears and screening for STDs, breast cancer, colon cancer, osteoporosis, cardiovascular
risks, and depression
[Kojic 2007]
By 2015, more than one half of all HIV-infected individuals in the United States will be older than 50 years of
age because of the success of antiretroviral therapy. Currently, approximately 30% of women with HIV are 50
years of age or older.
transition. Menopause is defined as the permanent cessation of menstruation caused by the loss of ovarian
function and is clinically measured as the absence of menses for 12 months in the absence of other etiologies.
Biochemically, menopause is associated with a persistently elevated follicle stimulating hormone level and
diminished estradiol level. Certain medical conditions, such as osteoporosis and cardiovascular disease, have
been linked with estrogen deficiency. HIV-infected women may be at increased risk for these conditions as
well.
2013]
For example, one study suggested that vascular elasticity is lower in women,
[Coutinho
and decreased estrogen and androgen levels in HIV-infected women may exacerbate atrial stiffness
[Karim 2013]
undergoes transition to menopause is important. Of note, symptoms associated with menopause are also
commonly associated with HIV infection itself.
For additional information from inPractice on issues related to aging in HIV-infected patients, click here.
Age of Menopause
Earlier age of menopause has been associated with increased risk for medical diseases and increased
mortality. Although the overall median age of menopause in the United States is 51.4 years,
conflicting data as to whether HIV infection is associated with an earlier onset.
[Imai 2013]
[Gold 2001]
there are
use, black race, and lower education level have been associated with an earlier onset of menopause in the
general population.
Lower CD4+ cell count, low physical activity, and injection drug
Symptoms of Menopause
The symptoms associated with menopause appear to be similar in HIV-positive and HIV-negative women.
However, the severity of symptoms may be altered.
have more vasomotor symptoms. More severe immunosuppression is associated with diminished vasomotor
symptoms. Women with depressive symptoms, reports of negative life events, and those receiving public
assistance report higher rates of menopausal symptoms. Irritability, depression, emotional liability, and
reduced concentration may be 25% to 50% more prevalent in HIV-infected women.
[Zablotsky 2003]
Syphilis
Gonorrhea/chlamydia
Depression screening
[Kojic 2007]
The importance of screening older adult populations for sexually transmitted diseases may be
underappreciated. However, factors that could increase the risk of acquiring a sexually transmitted disease
among older adults include the loss of a spouse
[Smith 2009]
[Stall 1994]
well as men are routinely screened for sexually transmitted diseases, particularly after acquiring a new sexual
partner.
For additional information from inPractice on the aging HIV population, click here.
Because primary care physicians will provide an increasing amount of care for HIV-infected women
over time, they will need to become more knowledgeable of critical management considerations when
treating HIV-infected women and more comfortable determining when specialty consultation is
needed
Routine clinical care for HIV-infected women should include immunizations, cardiovascular disease
risk assessment, psychosocial assessment, and screening for tuberculosis, breast cancer,
depression, STDs, cervical cancer, and anal cancer
The US Department of Health and Human Services adult antiretroviral therapy guidelines recommend
that all HIV-infected persons initiate antiretroviral therapy regardless of CD4+ cell count to prevent
sexual transmission of HIV in addition to preventing disease progression in the
individual (Management Guidelines)
[DHHS ART]
Factors that should be considered when selecting an initial antiretroviral therapy regimen for women
infected with HIV include: childbearing potential and use of hormonal contraceptives, HIV serostatus
of partners, risk for adverse effects of antiretroviral agents, comorbidities, and anticipated
antiretroviral adherence
When counseling HIV-infected women on the use of safe and effective contraception, primary care
physicians can explain the importance of dual forms of contraception: barrier (condom) and hormonal
(or sterilization)
Pharmacokinetic interaction should be considered when oral contraceptives and antiretroviral agents
are used together and certain agents should not be used concurrently
The DHHS recommends use of antiretroviral therapy by all HIV-infected pregnant women to reduce
the risk of mother-to-child transmission of HIV regardless of CD4+ cell count (Management
Guidelines)
[DHHS Perinatal]
The US Centers for Disease Control and Prevention recommend routine prenatal HIV screening in the
first trimester for all pregnant women, with consideration of repeat testing in the third
trimester (Management Guidelines)
All postmenopausal women, including those with HIV infection, should undergo routine health
screening, including annual Pap smears and screening for STDs, breast cancer, colon cancer,
osteoporosis, cardiovascular risk factors, and depression.
[Kojic 2007]
Primary care physicians will provide an increasing amount of care for HIV-infected women. Increased
identification and early initiation of treatment of HIV infection with simpler and more potent antiretroviral therapy
has resulted in increased longevity and decreased mortality. Sex-specific issues such as pregnancy, breast
and cervical cancer screening and prevention, and menopause have become more important components of
the overall care of HIV-infected women. As such, HIV-infected women will rely less on specialized care and
more on primary care physicians. Therefore, primary care providers need to become more knowledgeable of
critical management considerations for this population and more comfortable determining when specialty
consultation is needed. In general, the management of HIV-infected women in the primary care setting shares
many similarities with the management of HIV-uninfected women but with some important differences. This
section of the module will highlight key aspects of care provision for HIV-infected women that should be
considered in the primary care setting.
Routine clinical care for HIV-infected women should include all of the following:
Immunizations: vaccine recommendations are generally similar between HIV-positive and HIV-negative
patients with the exclusion of live viral-based vaccines
Tuberculosis screening: screening for latent tuberculosis infection should be performed at the time of HIV
diagnosis and annually thereafter in HIV-infected women with an ongoing risk for tuberculosis acquisition (C)
Cardiovascular disease risk screening: HIV-infected patients should be screened for traditional modifiable risk
factors, including cigarette smoking, hypertension, hyperlipidemia, diabetes, and obesity, because HIV
infection itself may increase cardiovascular disease risk.
addressed at each physician visit with behavioral and pharmacologic interventions as appropriate
[Currier 2008]
Breast cancer screening: HIV-infected women should follow standard age-based recommendations for regular
mammograms and breast self-examinations established for all women, regardless of HIV status
care. A multidisciplinary team that incorporates social services, mental health, and case management is often
required to maintain ongoing clinical care and medication compliance in this population
Depression screening: HIV-infected patients should receive ongoing screening for depression, with referral for
appropriate mental health intervention when indicated. This is especially important for HIV-infected women as
the rate of depressive symptoms or disorders in this population is nearly double that in HIV-infected men.
2001; Cook 2002a]
In addition, 1 in 5 HIV-infected women meet the classification for major depressive disorders
[Morrison 2002]
several negative sequelae, including increased rates of all-cause and AIDS-related mortality,
2002b]
2007]
[Ickovics
potentially higher rates of sexually transmitted diseases (STDs) and substance abuse,
[Fialho 2013]
[Cook
STD screening: Sexually active women should receive routing screening for STDs, including for gonorrhea,
chlamydia, trichomonas, syphilis, bacterial vaginosis, vulvovaginal candidiasis, herpes simplex virus, and
human papillomavirus. STDs can facilitate HIV transmission by increasing genital shedding of HIV.
1997]
[Cohen
STD screening should also be conducted after a new HIV diagnosis, with a new sexual partner, following a
condom malfunction, after unprotected intercourse, or when there is a known exposure to an STD.
Cervical cancer screening: Cancer screening, including human papillomavirus testing and a Pap test, should
be conducted every 6 months in the first year after HIV diagnosis and annually thereafter, unlike HIV-negative
women who now require screening every 3 years.
is due to the 4-5 times higher incidence of cervical intraepithelial neoplasia in HIV-positive women compared to
their HIV-negative peers.
Anal cancer screening: Anal cytologic screening is now being recommended for HIV-infected women, followed
by high-resolution anoscopy in women with abnormal cytologic results, regardless of history of receptive anal
intercourse.
[CDC OI]
The US Department of Health and Human Services adult antiretroviral therapy guidelines recommend that all
HIV-infected persons initiate antiretroviral therapy regardless of CD4+ cell count to prevent sexual
transmission of HIV in addition to preventing disease progression in the individual (Management
Guidelines).
[DHHS ART]
Factors that should be considered when selecting an initial antiretroviral therapy regimen
for women infected with HIV include childbearing potential and use of hormonal contraceptives, HIV serostatus
of partners, risk for adverse effects of antiretroviral agents, comorbidities, and anticipated antiretroviral
adherence. Despite recommendations for antiretroviral therapy initiation, considerable numbers of HIV-infected
women with clinical indications for treatment in the United States are not receiving antiretroviral therapy. In
addition, there are several notable differences between the course of antiretroviral therapy in HIV-infected
women vs that in HIV-infected men, including higher rates of treatment-associated adverse events
2010; Mills 2009; Brinkman 1999; Bersoff-Matcha 2001; Mazhude 2002; Sanne 2005]
[Lucas 1999]
in women vs men.
There are special considerations for reproductive health in HIV-infected women when compared with the
general population. These include issues related to contraception, pregnancy, and menopause. Women with
HIV infection often feel stigmatized by their diagnosis and, therefore, do not seek appropriate care, which can
be detrimental to all facets of reproductive health. Primary care physicians can play an important role in
addressing these issues by initiating discussions with HIV-infected women during routine primary care
appointments.
When counseling HIV-infected women on the use of safe and effective contraception, primary care physicians
can explain the importance of dual forms of contraception: barrier (condom) and hormonal (or sterilization).
Dual mechanisms are necessary because antiretroviral agents may alter the clinical effectiveness of many of
the available contraceptive choices, and contraceptive agents may alter the efficacy of some antiretroviral
agents. Additionally, barrier (condom) contraception is also important to reduce the risk of sexual transmission
of HIV to intimate partners. Virologic responses to antiretroviral therapy should be monitored closely when
used in combination with nonbarrier contraceptives. Pharmacokinetic interaction should be considered when
combined oral contraceptives and antiretrovirals are used together and certain agents should not be used
concurrently. Limited data exist regarding the use of implantable or intravaginal contraception in HIV-infected
women. However, the Centers for Disease Control and Preventions Medical Eligibility Criteria for
Contraceptive Use lists all combined hormonal contraceptive methods (including the patch and vaginal ring) as
Category 1 (no restriction for use) for women at high risk for HIV or with HIV or AIDS.
[CDC MEC]
containing intrauterine device (Tcu-380A IUD) and the levonorgestrel-releasing intrauterine contraceptive
system are acceptable choices for HIV-infected women at low risk for acquiring STDs.
[DHHS ART]
The US Department of Health and Human Services recommends the use of antiretroviral therapy by all HIVinfected pregnant women to reduce the risk of mother-to-child transmission of HIV regardless of CD4+ cell
count (Management Guidelines).
[DHHS Perinatal]
pregnancy. The Centers for Disease Control and Prevention recommend routine prenatal HIV screening in the
first trimester for all pregnant women, with consideration of repeat testing in the third trimester (Management
Guidelines)
In addition, women who present to labor and delivery with unknown HIV status or
who are at risk for HIV acquisition should undergo rapid HIV testing. If the results of the rapid test are positive
or unknown, intravenous zidovudine should be administered without waiting for confirmation of HIV status.
Primary care physicians should involve both obstetrical providers and HIV specialists in the medical care of
HIV-infected pregnant women throughout the entire gestational period especially regarding selection
ofappropriate antiretroviral therapy, management of prenatal care and delivery, and treatment of HIV-exposed
infants. Key management strategies for HIV-infected pregnant women include the following (Management
Guidelines)
[DHHS Perinatal]
HIV-infected pregnant women should follow the same vaccination schedule as nonpregnant HIV-infected
individuals, with particular attention to the need for hepatitis A and B vaccination (if antibodies are not present)
and influenza virus vaccine, inactivated
HIV-infected pregnant women should be monitored with greater frequency for antiretroviral treatment response
and complications
Intravenous zidovudine administered near delivery is recommended for HIV-infected pregnant women with
HIV-1 RNA > 1000 copies/mL or unknown HIV-1 RNA levels unless there is evidence of resistance or toxicity
Women whose HIV-1 RNA remains > 1000 copies/mL near the time of delivery should be advised to
undergo Cesarean section
Women should continue their oral antiretroviral therapy regimen as prescribed before and during labor and
delivery
However, decisions regarding antiretroviral therapy continuation postpartum should be made with consultation
between the woman and her HIV provider, preferably before delivery
Breastfeeding is currently not recommended in any HIV-infected women with access to clean water and
formula, regardless of HIV-1 RNA level
Based on the success of antiretroviral therapy, the proportion of HIV-infected women who are 50 years of age
or older continues to increase, with a concomitant increase in the need for effective management of
menopausal symptoms in this group. All postmenopausal women, including those with HIV infection, should
undergo routine health screening, including annual Pap smears and screening for STDs, breast cancer, colon
cancer, osteoporosis, cardiovascular risk factors, and depression.
[Kojic 2007]
important interactions may occur between HIV infection and menopause, and primary care physicians may be
better able to assist HIV-infected women experiencing complications of menopause if they have an
understanding of this potential interplay. Several potential associations that may be useful to consider include
Earlier menopause in HIV-infected women may be associated with lower CD4+ cell count, low physical activity,
and injection drug use
[Schoenbaum 2005]
HIV-infected women may be at increased risk for conditions linked with estrogen deficiency
Current evidence supports the use of hormone replacement therapy for relief of menopausal symptoms,
especially the vasomotor effects. However, there are no available data demonstrating safety in the HIV
population. Whether or not there are drugdrug interactions between hormone replacement therapy and
antiretroviral therapy is unknown.
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HIV
HIV-Infected Women
Summary
Introduction
Immunizations
Oral Contraceptives
Injectable Contraceptives
Barrier Contraceptives
STDs
Antiretroviral Therapy
Treatment Initiation
Treatment Outcomes
Treatment Complications
Treatment of Depression
Initial Evaluation
Immunizations
Intrapartum Management
Mode of Delivery
Postpartum Management
Age of Menopause
Symptoms of Menopause
Additional Considerations
Supporting Assets
References
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References
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Keywords: Women