ACOG Issues Guidelines on Care for HIV-Infected Women

Megan Brooks

November 23, 2010

November 23, 2010 — In a practice bulletin issued today, The American College of Obstetricians and Gynecologists (ACOG) notes that women with HIV/AIDS are living longer, healthier lives and their need for routine gynecologic care is increasing.

The purpose of the practice bulletin, they state, "is to educate clinicians about routine HIV screening practices as well as basic women's health screening and care, family planning, and preconception care for women who are infected with HIV."

According to ACOG, roughly 27% of all HIV/AIDS cases in the United States today are among women, up from 7% in 1985. Black and Hispanic women are disproportionately affected, accounting for 80% of all HIV-positive women today. Heterosexual contact accounts for 72% of HIV transmission among women in the United States.

"Most of the women living with HIV today in the US are in their prime reproductive years," Hal C. Lawrence, MD, vice president of practice activities for ACOG, noted in a prepared statement.

"As the number of women with HIV diagnoses increases, ob-gyns will, if they haven't already, begin to see more patients who are HIV positive. These guidelines cover the recommended health screenings, counseling, and routine gynecologic care for these women," Dr. Lawrence said.

Gynecologic Care

ACOG recommends routine HIV screening for all women ages 19 to 64 years and targeted screening for women who have risk factors that fall outside this age range, for example, sexually active or intravenous drug-using adolescents younger than 19 years.

"If counseling and written consent are not required, the patient should be notified that testing will be performed unless the patient declines (opt-out screening)," the bulletin states.

Although the Centers for Disease Control and Prevention (CDC) and ACOG both recommend that all reproductive-age women be screened for HIV at least once in their lifetime, there is no consensus on how often they should be retested. ACOG recommends that obstetrician-gynecologists annually review patients' risk factors for HIV and assess the need for retesting.

ACOG recommends that the following groups of women be offered repeat HIV screening at least annually:

  • injection drug users;

  • those who have sex partners who are injection drug users or who are HIV positive;

  • those who exchange sex for drugs or money;

  • those who have been diagnosed with a sexually transmitted disease in the past year; and

  • those who have had more than 1 sex partner since their last HIV test.

The CDC estimates that about 21% of HIV-infected individuals who are unaware of their HIV infection account for 54% of new infection transmissions. They also estimate that informing infected persons who are unaware of their status that they are HIV infected could reduce the number of new sexually transmitted infections (STIs) by more than 30%.

The practice bulletin recommends that HIV-positive women be treated aggressively for other STIs. "Having another [STI] in addition to HIV may increase the risk of transmitting HIV to others," Roxanne M. Jamshidi, MD, who assisted in the development of the new guidelines, noted in a written statement.

In particular, women with HIV have a higher rate of bacterial vaginosis and yeast infections than other women, ACOG notes. These infections "appear to be more common and more persistent among women with HIV who are immunosuppressed," Dr. Jamshidi points out, and therefore may require slightly longer treatment.

ACOG recommends that women with HIV infection have cervical cytology screening twice in the first year after diagnosis and annually thereafter. Routine colposcopy is recommended for HIV-infected women with atypical squamous cells of undetermined significance or higher-grade abnormality.

"Human papillomavirus [HPV] testing currently has no role in the triage of HIV-infected women with abnormal cytology results or for follow-up after treatment for [cervical intraepithelial neoplasia]," the practice bulletin states.

HIV infection is not considered a contraindication to HPV vaccine administration, the bulletin reminds clinicians, and "CDC recommendations for HPV vaccination of children and adolescents should be followed for both HIV-infected and non–HIV-infected populations."

Contraception

The bulletin recommends dual contraception (condoms and additional contraception) as the best way for women with HIV to reduce the risk of transmitting HIV and other STIs and to prevent pregnancy.

"Women with HIV will need to use condoms each time they have intercourse, but they also need to use additional contraception to prevent unintended pregnancy," said Dr. Jamshidi.

Intrauterine devices are often a good contraceptive option for HIV-positive women, ACOG notes in a prepared statement. Although hormonal contraception is safe for HIV-positive women, combined (estrogen and progestin) oral contraceptives are generally not recommended for women taking certain highly active antiretroviral therapy (HAART) regimens because of the potential of each to lessen the effectiveness of the other medication.

Preconception Care and Pregnancy

The advent of HAART and the significant reduction of mother-to-child transmission of HIV in the United States has prompted more HIV-positive women to choose to have children, ACOG points out. "Accordingly, reproductive plans, including preconception counseling and counseling regarding reversible methods of contraception, if appropriate, should be discussed with HIV-infected women of childbearing age," the practice bulletin advises.

"Data regarding the effects of antiretroviral drugs on the developing fetus are limited, and the benefits and potential risks of HAART during pregnancy should be discussed with the patient," the document reads. "Women with HIV can have healthy pregnancies and healthy babies, but it takes careful planning," added Dr. Jamshidi.

Achieving pregnancy without transmitting the virus to a noninfected partner is best accomplished through artificial insemination. Donor insemination from an HIV-negative male is the safest option for women who are HIV negative but whose partners are HIV positive, the practice bulletin advises. An HIV-infected woman whose male partner is HIV negative can be inseminated with her partner's sperm at the time of ovulation.

Menopause

The new guidelines also address menopause in HIV-positive women. Studies suggest that the average age of menopause among HIV-positive women is about 3 to 4 years younger than other women. "This may be due to smoking, drug abuse, and low body weight, which are common among women with HIV," said Dr. Jamshidi.

The guidelines also emphasize that low bone mass is more prevalent among HIV-positive women nearing menopause, but data to date are lacking on the treatment of osteoporosis in this subset of women. Increasing physical activity, stopping smoking, and taking calcium and vitamin D supplements, however, are standard suggestions to prevent further bone loss.

Obstet Gynecol. 2010;117:1492-1509.

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