Guia Vih Mujer

THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
WOMEN S HEALTH CARE PHYSICIANS
P R AC T I C E
BUL L E T I N
CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN GYNECOLOGISTS
NUMBER 117, DECEMBER 2010
Gynecologic Care for Women With

Human Immunodeficiency Virus
The increased use of screening tests has led to the identification of large numbers of women with human immunodeficiency virus (HIV). Consequently, there is an increased role for obstetriciangynecologists in caring for infected
women. Women infected with HIV are living longer, healthier lives and, therefore, the need for rotuine gynecologic
care has increased. The purpose of this document is to educate clinicians about routine HIV screening practices
as well as basic womens health screening and care, family planning, and preconception care for women who are
infected with HIV.
Background
Basic Epidemiology and Prevalence
In the United States, women account for a growing
proportion of patients with human immunodeficiency
virus (HIV) and acquired immunodeficiency syndrome
(AIDS) (from 7% in 1985 to 27% in 2007) (1). Heterosexual contact is responsible for 72% of HIV transmission among women in the United States, and women
of color are disproportionately affected, accounting for
80% of HIV-infected women (1, 2). In most women with
HIV, the infection is diagnosed during their reproductive
years (1).
Antiretroviral Therapy for Nonpregnant

HIV-infected Women
Treatment of HIV and AIDS should be provided by
a health care practitioner with expertise in HIV. Such
expertise has been shown to be a factor that prolongs the
life of HIV-infected individuals (3, 4). A team approach
is optimal to address both the medical and social

complexity of HIV infection. In addition to obtaining a
comprehensive medical history, including a gynecologic
history and an HIV-related history, a detailed social history also should be obtained. Women with HIV often
have life circumstances, such as alcohol or drug addiction, psychiatric illness, and domestic violence, that require
special attention (5). Appropriate sensitivity is needed to
address these life circumstances and to treat HIV.
In nonpregnant adults, initiation of antiretroviral
therapy is recommended for patients with a history of an
AIDS-defining illness (Box 1) or a CD4 T-cell (or CD4)
count of less than 500 cells per cubic millimeter. For
patients with CD4 counts of 500 cells per cubic millimeter or greater, antiretroviral therapy may be offered (6).
Antiretroviral medications select for resistant mutations
when used as monotherapy; therefore, combinations of
three or more drugs, often called highly active antiretroviral therapy (HAART), are used and strict adherence to
the dose regimens is critical. There are currently more
than 20 U.S. Food and Drug Administration (FDA)-
Committee on Practice Bulletins Gynecology. This Practice Bulletin was developed by the Committee on Practice BulletinsGynecology with the
assistance of Roxanne Jamshidi, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care.
These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the
needs of the individual patient, resources, and limitations unique to the institution or type of practice.
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OBSTETRICS & GYNECOLOGY
not be used as a component of combination therapy in

this setting unless the benefits clearly outweigh the risks.
Liver toxicity has not been seen in women undergoing
single-dose nevirapine therapy during labor for prevention of perinatal transmission (6).
Box 1. Conditions Defining Acquired

Immunodeficiency Syndrome
Candidiasis (bronchi, trachea, lungs, or esophagus)
Cervical cancer (invasive)
Coccidioidomycosis, cryptococcosis, and cryptosporidiosis
Cytomegalovirus disease
Encephalopathy (human immunodeficiency virusrelated)
Herpes simplex (severe infection)
Histoplasmosis
Isosporiasis
Kaposi sarcoma
Lymphoma (certain types)
Mycobacterium avium complex
Pneumocystis jiroveci pneumonia
Pneumonia (recurrent)
Progressive multifocal leukoencephalopathy
Salmonella septicemia (recurrent)
Toxoplasmosis of the brain
Tuberculosis
Wasting syndrome
Clinical Considerations and

Recommendations
Who should be screened for HIV infection
and what tests are available for screening?
Human immunodeficiency virus testing is an important
and effective HIV prevention strategy. Therefore, the
American College of Obstetricians and Gynecologists
(the College) recommends routine HIV screening of
women aged 1964 years and targeted screening for
women with risk factors outside of that age range; for
example, sexually active or intravenous drug using
individuals younger than 19 years (8). Although the
Centers for Disease Control and Prevention (CDC) and
the College both recommend that reproductive-aged
women be tested at least once in their lifetime, there is
no consensus regarding how often women should be
retested. The College recommends that obstetrician
gynecologists annually review patients risk factors for
HIV and assess the need for retesting. Repeat HIV testing should be offered at least annually to women who
have the following risk factors:
Data from 1993 revised classification system for HIV infection and
expanded surveillance case definition for AIDS among adolescents
and adults. MMWR Recomm Rep 1992;41(RR-17):119.
approved antiretroviral agents from six medication

classes that can be used to formulate combination regimens. Although long-term experience with antiretroviral
agents is still limited, certain drugs merit special consideration in the treatment of women. Efavirenz is the
preferred nonnucleoside reverse transcriptase inhibitor
for the patients nave to antiretroviral therapy, but it also
is considered a possible teratogen because of data showing an increased risk of central nervous system defects
in primates and a small number of case reports of neural
tube defects in humans (FDA pregnancy category D)
(7). Women offered efavirenz should be made aware of
the potential teratogenic effects of this drug when used
during pregnancy and that it is important to use effective
and consistent contraception. The nonnucleoside reverse
transcriptase inhibitor nevirapine is associated with an
increased risk of symptomatic liver toxicity that can be
severe and life-threatening. This risk is greater in women
than men and is highest among those initiating nevirapine therapy with CD4 counts of greater than 250 cells
per cubic millimeter (6). Therefore, nevirapine should
Are injection drug users

Have sex partners who are injection drug users or
are infected with HIV
Exchange sex for drugs or money
Have received a diagnosis of another sexually transmitted infection (STI) in the past year
Have had more than one sex partner since their most
recent HIV test.
Obstetrician gynecologists also should encourage
women and their prospective sex partners to be tested
before initiating a new sexual relationship. In addition,
periodic retesting could be considered even in the
absence of risk factors depending on clinical judgment,
geography (eg, living in a high-prevalence community),
and the patients wishes. Some patients may not always
disclose or admit to high-risk behaviors or might not
perceive their behaviors to be high risk.
The Centers for Disease Control and Prevention has
estimated that approximately 21% of HIV-infected individuals who are unaware of their HIV infection account
for 54% of new infection transmissions (9). It is estimated
Practice Bulletin
Gynecologic Care for Women With HIV 1493
that informing infected individuals who are unaware of

their status that they are HIV-infected could reduce the
number of new STIs by more than 30% (10). Human
immunodeficiency virus testing is an effective preventive
intervention partly because knowing ones serostatus may
lead to changes in behavior. A meta-analysis estimated
that the number of cases of unprotected anal or vaginal
intercourse with HIV-seronegative partners was reduced
by 68% among HIV-infected individuals who knew of
their positive serostatus compared with those who were
unaware of their status (11). In addition, knowledge of
serostatus soon after conversion allows more opportunity for treatment that can dramatically increase survival
rates and potentially decrease the risk of transmission by
decreasing HIV viral load. In 2006, 36% of individuals
with AIDS received the diagnosis within 1 year after their
first positive HIV test result, demonstrating the lost opportunities for earlier diagnosis and treatment (1).
Because of inadequate detection of HIV infection
and the potential benefit of increased numbers of individuals knowing their HIV serostatus, the CDC revised
its HIV testing recommendations in 2006. The Centers
for Disease Control and Prevention now recommends routine voluntary HIV screening as a normal part of medical
practice (12). Except when required by state law, prevention counseling and separate written consent are no longer
considered necessary. Because state laws continue to
change, clinicians should be familiar with their local laws.
A useful resource is the Compendium of State HIV Testing
Laws, which can be found at http://www.nccc.ucsf.edu/
consultation_library/state_hiv_testing_laws). 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). From 2004 to 2007, CDC
surveillance has shown a 15% increase in the number of
HIV diagnoses, which is likely due in part to the CDCs
revised recommendations for testing (1). For patients initially reluctant to be tested, brief behavioral counseling has
been shown to improve HIV testing acceptance (13).
Diagnostic tests for HIV either detect host antibodies made against different HIV proteins or detect directly
the whole virus or components of the virus (such as HIV
RNA). Antibody testing begins with a sensitive screening test (eg, the enzyme immunoassay or rapid test), generally performed on blood samples. A positive screening
test result needs to be followed by a confirmatory test,
such as the Western blot or immunoflorescence assay
(IFA). The enzyme immunoassay and Western blot testing combination is the oldest HIV diagnostic test and is
readily available. When the test is used after seroconversion (usually 68 weeks after initial HIV infection),
the test has a high sensitivity of 99.399.7% and a high
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specificity of 99.7% (14). Human immunodeficiency

virus diagnostic tests performed on saliva and urine
samples also are available, but the results of these tests
need to be confirmed by Western blot or IFA.
Standard antibody testing can take up to 1 week or
longer to complete; consequently, many HIV-infected
individuals do not return for results and are lost to
follow-up (15). Rapid HIV testing has the potential
advantage of decreasing costs and increasing the number of patients who receive their results (16, 17). It is
especially useful in venues where patients often may not
return to learn their results (eg, emergency departments
and urgent care clinics) and in situations where positive
test results will generate immediate action (eg, during
labor and delivery or after occupational exposure) (18).
Rapid tests approved by the FDA include six clinically available tests, four of which have Clinical Laboratory Improvement waivers. Sensitivity and specificity
of the available tests generally exceed 99%. Only one
rapid test is approved for use with oral fluid. Rapid tests
are considered antibody screening tests, and positive test
results require confirmatory testing with Western blot or
IFA. However, in settings where urgent action is needed,
such as after occupational exposure or for prevention of
perinatal transmission in labor, decisions should be made
based on the positive screening test result. Patients with
positive rapid test results and negative or indeterminate
confirmatory test results should have follow-up confirmatory testing after 4 weeks.
Gynecologic providers should consider a diagnosis
of acute HIV infection in patients who have a compatible clinical syndrome, even in the absence of reported
risk behaviors. An estimated 4090% of patients acutely
infected with HIV will experience fever, lymphadenopathy, pharyngitis, skin rash, myalgias or arthralgias,
and other symptoms. When acute retroviral syndrome
is suspected, a plasma HIV RNA test should be used in
conjunction with an HIV antibody test for diagnosis. A
low-positive HIV RNA level (less than 10,000 copies per
milliliter) may represent a false-positive test result because
values in acute infection generally are high (greater than
100,000 copies per milliliter) and are associated with
increased risk of both perinatal and sexual transmission.
How are recommendations for cervical

cancer screening and treatment of dysplasia
different for HIV-infected women?
Women infected with HIV are at an increased risk of
high-risk human papillomavirus (HPV) infection and
cervical intraepithelial neoplasia (CIN) (1921). The incidence, prevalence, and persistence of HPV, including
high-risk subtypes, are more common in the setting of
Gynecologic Care for Women With HIV
HIV infection and increase with worsening immunosuppression (ie, decreasing CD4 count and increasing
viral load) (19, 2123). However, among women who
receive regular screening and recommended follow-up
treatment, the incidence of invasive cervical cancer is
not higher among HIV-infected women compared with
HIV-negative women (24, 25). Therefore, women with
HIV infection should have cervical cytology screening
twice in the first year after diagnosis of HIV and annually
thereafter (26, 27).
The optimal management of HIV-infected women
with abnormal cervical cytology test results, specifically
women with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesion (LSIL), remains unclear. The 2006 American
Society for Colposcopy and Cervical Pathology Consensus
Guidelines endorse similar management schemes for
ASC-US (including the option of reflex high-risk HPV
testing for triage) and LSIL irrespective of HIV status
(28). However, the more recent CDC guidelines, although
based on limited and conflicting data regarding the utility
of HPV testing in HIV-infected women with ASC-US,
recommend routine colposcopy for HIV-positive women
with ASC-US or higher grade abnormality (27). In two
prospective studies of HIV-infected women with ASCUS, approximately 30% of participants had evidence of
oncogenic HPV, a finding that would support the use of
HPV testing in this population if HPV testing remained
highly sensitive (29, 30). However, one study reported a
sensitivity of HPV testing for the detection of CIN 2 or
higher of 100% (30), whereas another study found HPV
testing to be of insufficient sensitivity (50%) for detecting high-grade CIN (29). Human papillomavirus testing
currently has no role in the triage of HIV-infected women
with abnormal cytology results or for follow-up after
treatment for CIN.
It remains unclear whether HIV-infected women with
mild cytologic abnormalities are at a similar or increased
risk of clinically significant disease as compared with
the uninfected population. In a cross-sectional study
of HIV-infected women and nonHIV-infected women
with ASC-US and LSIL, HIV-infected women were as
likely as HIV-negative women to have CIN 2 or higher
on biopsy (31). For HIV-infected women with ASC-US
or LSIL and no histologic evidence of high-grade CIN,
the absolute risk of progression to CIN 2 or higher is
low (approximately 12%) (32). Among a cohort of HIVinfected women, CIN 1 was also shown to infrequently
progress to more advanced disease (33). Therefore, repeat
cytologic testing at 6 months and 12 months is recommended for HIV-infected women with mild cytologic
abnormalities, satisfactory colposcopy results, and no
evidence of histologic high-grade disease (28).
In nonpregnant women aged 21 years and older, both

excision and ablation are acceptable treatment modalities in the presence of histologic diagnoses of CIN 2 or
CIN 3 and satisfactory colposcopy results, regardless of
HIV status (28). Women with HIV infection appear to be
more likely to have persistent or recurrent disease after
treatment. Glandular involvement and the presence of
positive excisional margins have been associated with
increased likelihood of treatment failure among HIVinfected women (34), although such associations have not
been consistently seen across all studies (35). In general,
excisional therapies have been shown to effectively prevent progression to invasive cervical cancer, although
re-excision may be necessary in some patients (36, 37).
Despite the increased recurrence rates after excisional or
ablative treatment, most treatment failures and recurrences were associated with low-grade disease, which may
be associated with new HPV infections (38). Follow-up
with cervical cytology alone or cytology and colposcopy
together at 6-month intervals over the first year after treatment is recommended (27, 28). Although HPV testing at
612 months is another option for follow-up, the CDC
does not endorse its use in this setting (27, 28). Because
of a dramatic increase in the amount of HIV shed in the
genital tract 24 weeks after treatment for CIN, abstinence from vaginal intercourse should be emphasized
until complete healing has occurred (39).
Women with HIV infection, particularly those with
evidence of high-grade CIN before or at the time of
hysterectomy, are at a significantly increased risk of subsequent vaginal cytologic abnormalities compared with
the general population (40). Thus, continued cytologic
surveillance is warranted in HIV-infected women with a
history of CIN 2 or greater who undergo hysterectomy.
In general, it should be noted that HIV-positive women
have higher rates of anogenital neoplasia (including not
only vaginal, but also vulvar and perianal neoplasia) (41,
42). Close attention should be paid to these areas for any
HIV-infected woman undergoing assessment for cervical or vaginal cytologic abnormalities.
Women with HIV infection also are at an increased
risk of high-grade anal intraepithelial neoplasia and anal
cancer compared with the general population (27). Even
with the use of HAART, high-grade anal intraepithelial
neoplasia was found in 9% of HIV-infected women in
a large prospective study (43). Although screening with
anal cytology every 23 years has been shown to provide
life-expectancy benefits and to be cost effective in HIVnegative homosexual and bisexual men, the benefits in
women remain unclear (44). Women with HIV infection
should be routinely questioned about rectal symptoms,
such as bleeding or pain. Inspection and digital rectal
examination may aid in the detection of anal cancer. Anal
Practice Bulletin
cytology should be considered if resources, such as highresolution anoscopy, are available to evaluate and treat
any abnormal findings (45). In addition, it may be necessary to examine atypical appearing genital warts or those
not responding to treatment with biopsy to exclude preinvasive or invasive lesions because squamous cell carcinomas arising in or resembling genital warts might occur
more frequently among immunosuppressed persons.
Although adolescents with HIV have a higher incidence of cervical dysplasia than those who do not have
HIV (4648), the incidence of high-grade abnormalities
(both high-grade squamous intraepithelial lesion and
CIN 2 or CIN 3) appears to be low (46). Therefore,
cytologic surveillance in this population is recommended twice in the first year after diagnosis and annually
thereafter, with referral for colposcopy for any cytologic
abnormality other than ASC-US (27, 49). Adolescents
with ASC-US may be monitored with repeat cytology
alone or referred to colposcopy.
Another issue of concern in HIV-infected adolescents, a significant percentage of whom are infected
perinatally, is the use of the HPV vaccine. Although data
on the safety of the quadrivalent vaccine in HIV-infected
children has been demonstrated, efficacy of the currently
available HPV vaccines in women or girls with HIV has
not yet been established (50). Human immunodeficiency
virus infection is not considered a contraindication to
vaccine administration, and CDC recommendations for
HPV vaccination of children and adolescents should be
followed for both HIV-infected and nonHIV-infected
populations (27, 51, 52).
In HIV-infected women, how does diagnosis

and treatment of bacterial vaginosis or vulvovaginal candidiasis differ from that in non
HIV-infected women?
A similar prevalence of bacterial vaginosis, as identified
by Gram stain, was seen among HIV-infected and non
HIV-infected women in the Womens Interagency HIV
Study sponsored by the National Institutes of Health
(53). A cross-sectional study of the prevalence of bacterial vaginosis among women in the CDC-sponsored HIV
Epidemiology Research Study (HERS) cohort demonstrated an increased prevalence of bacterial vaginosis
among HIV-infected women identified by Gram stain
(47% of women), but these results were not shown using
clinical criteria.
Among the HIV-infected women, the use of antiretroviral drugs was associated with a lower prevalence
of bacterial vaginosis than when antiretroviral drugs
were not used (54). A longitudinal analysis of this same
cohort found an increased prevalence of bacterial vagi-
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nosis, but these results were primarily thought to occur

because HIV-infected women were more likely to have
more persistent infections rather than more incident (ie,
frequent) infections. This was particularly true for HIVinfected women with CD4 counts of less than 200 cells
per cubic millimeter (55). The treatment regimens for
bacterial vaginosis in HIV-infected women are the same
as those for nonHIV-infected women.
Vaginal colonization with Candida albicans and vulvovaginal candidiasis are more frequent among HIVinfected women than nonHIV-infected women (53, 56).
A longitudinal analysis of the HERS cohort revealed that
much of this difference can be attributed to immunosuppression; rates of vulvovaginal candidiasis among immunocompetent HIV-infected women (with CD4 counts of
greater than 500 cells per cubic millimeter) were similar
to those in nonHIV-infected women. However, among
HIV-infected women, increased rates of yeast colonization and vulvovaginal candidiasis were associated with
decreasing CD4 counts (57, 58). This same study showed
that although vulvovaginal candidiasis occurred with
higher incidence and greater persistence among HIVinfected women, the severity of the infections was not
increased.
For immunocompetent women with HIV infection,
treatment of vulvovaginal candidiasis is similar to that
for women without HIV infection (59). However, given
the persistence of symptomatic candidiasis among HIVinfected women, topical therapies are recommended to
be administered for at least 7 days, and fluconazole may
be more effective when given in two sequential 150-mg
doses 3 days apart (60). Long-term prophylactic therapy
with fluconazole at a dose of 200 mg weekly has been
shown to be effective in reducing colonization with
C albicans and symptomatic vulvovaginal candidiasis
in HIV-infected women, but this regimen is not recommended for routine primary prophylaxis in HIV-infected
women in the absence of recurrent vulvovaginal candidiasis (59, 61).
In HIV-infected women, how do diagnosis

and treatment of STIs differ from those for
nonHIV-infected women?
With few exceptions, the prevalence and treatment of
STIs are not affected by HIV serostatus. However, the
presence of STIs, especially ulcerative disease, increases
HIV shedding, which may increase the risk of HIV
transmission to partners (62, 63). Therefore, STIs should
be treated aggressively in women with HIV. The Centers
for Disease Control and Prevention recommends annual
screening for curable STIs (eg, syphilis, gonorrhea, and
chlamydia) among sexually active HIV-infected women,
with more frequent screening if indicated by symptoms

or risk behaviors (59).
Large cohort studies have not shown significant
differences in the prevalence of chlamydia, gonorrhea,
trichomoniasis, and syphilis by HIV serostatus (64, 65).
Chlamydia, gonorrhea, and trichomoniasis are diagnosed and treated among HIV-positive women using the
same diagnostic criteria and treatment regimens used for
the evaluation of HIV-negative women.
The Centers of Disease Control and Prevention guidelines for the treatment of pelvic inflammatory disease
(PID) do not differ by HIV infection status. Whether the
management of immunodeficient HIV-infected women
with PID requires more aggressive interventions, such as
hospitalization or administration of parenteral antimicrobial regimens, has not been adequately evaluated (59).
Some studies suggest that HIV-infected women may
initially have more severe symptoms, are more likely to
have tuboovarian abscesses, or require prolonged hospital courses, but overall response to standard therapy is the
same among HIV-infected and nonHIV-infected women
(6668).
In general, management and treatment of syphilis
among HIV-infected patients is the same as that among
nonHIV-infected patients. Although there are reports of
unusual serologic responses among HIV-infected individuals who have syphilis, these effects are uncommon. Both
treponemal and nontreponemal serologic tests for syphilis
can be interpreted in the usual manner for most patients
who are co-infected with Treponema pallidum and HIV
(59). Human immunodeficiency virus serostatus has been
shown to have a small effect on clinical manifestations
of primary and secondary syphilis. Compared with non
HIV-infected patients, HIV-infected patients with primary
syphilis are more likely to have multiple ulcers, and HIVinfected individuals with secondary syphilis more often
have concomitant genital ulcers (69). Although some
studies show no influence of HIV serostatus on successful syphilis treatment rates (70), other studies show
significantly more treatment failures or longer median
time to successful serologic response in HIV-infected
patients (71, 72). Although HIV-infected patients who
have early syphilis might be at an increased risk of neurologic complications and might have higher rates of treatment failures with currently recommended regimens, no
treatment regimens for syphilis have been demonstrated
to be more effective in preventing neurosyphilis in HIVinfected patients than the syphilis regimens recommended
for patients witouht HIV infection (73).
Herpes simplex virus type 2 (HSV-2), the most
common cause of genital ulcer disease, is more prevalent
among individuals with HIV infection, with approximately 70% of HIV-infected individuals coinfected with
HSV-2 (74). Accumulating epidemiologic evidence suggests that HIV acquisition and transmission are promoted
by HSV-2 infection and that HIV disease progression
is hastened by HSV-2 infection (75). The frequency,
severity, and duration of HSV-2 clinical reactivation
and frequency of subclinical infection are all increased
by HIV infection. Although HAART reduces the severity and frequency of symptomatic genital herpes, HIVinfected women have comparatively more genital ulcers
and frequent subclinical shedding still occurs among
these women receiving antiretroviral therapy (76, 77).
Suppressive or episodic therapy with oral antiviral agents
is effective in decreasing genital ulcers, genital HSV-2
shedding, as well as HIV genital shedding and plasma
HIV viral load among coinfected women (7883). The
treatment of HSV-2 in the context of HIV-1 coinfection
often requires a longer duration of treatment at higher
antiviral doses. Recommendations for suppressive and
episodic therapy can be found in the CDCs sexually
transmitted disease treatment guidelines (59).
As previously noted, HIV-infected women are more
likely to have HPV coinfection. This coinfection is manifested in the lower genital tract by the increased prevalence and incidence of genital warts compared with those
of nonHIV-infected women (41, 84). Although treatment
modalities for external genital warts do not differ in the
setting of HIV infection, individuals who are immunosuppressed because of HIV may have larger or more numerous warts, may not respond as well as immunocompetent
individuals to therapy for genital warts, and may have
more frequent recurrences after treatment (84, 85).
In HIV-infected women, how does treatment

of menstrual disorders differ from that in
nonHIV-infected women?
Women infected with HIV should receive the same evaluation and treatment for menstrual disorders as uninfected
women. Although menstrual disorders are frequently
reported by HIV-infected women, the role of HIV and
HIV-related immunosuppression in menstrual abnormalities is unclear. Some studies have shown that amenorrhea
and irregular cycles are more common among HIVinfected women (86, 87). Human immunodeficiency virus
serostatus was not associated with menstrual abnormalities
when data were controlled for age, ethnicity, body mass
index, smoking status, alcohol use, drug use, and parity. However, among HIV-positive women, those using
HAART and with higher CD4 counts were less likely to
have menstrual abnormalities (88). Among more immunosuppressed women (with CD4 counts of less than 200 cells
per cubic millimeter), there was a suggestion of increased
prevalence of long (greater than 90 days) or short (less
Practice Bulletin
than 18 days) cycles (89). In the setting of HIV infection, confounding variables, such as weight loss, chronic
disease, substance abuse, or use of psychotherapeutic
medications, may be related to menstrual disorders (90).
In HIV-infected women, how do the diagnosis

and treatment of menopausal symptoms differ
from those in nonHIV-infected women?
As life expectancies for women living with HIV increase,
more HIV-infected women are experiencing the menopause transition. Although data regarding the effect of
HIV on the age at menopause are not conclusive, studies
suggest that the mean age at menopause for HIV-infected
women is 34 years younger than that for uninfected
women (91). A variety of factors associated with earlier
menopause, including current smoking, substance abuse,
African American race, lower socioeconomic level, and
low relative body weight, are common among women
with HIV and may be a basis for the occurrence of
menopause at an earlier age (92). Baseline data from a
prospective study showed that HIV infection and immunosuppression were associated with an earlier age at the
onset of menopause (93). In the Womens Interagency
HIV Study cohort, the age at menopause was not affected
by HIV status, but prolonged amenorrhea (lasting longer
than 12 months) was more common among HIV-infected
women than among nonHIV-infected women. Serum
follicle-stimulating hormone levels in approximately one
half of the HIV-infected women with prolonged amenorrhea did not necessarily indicate menopausal status, and
HIV-infected women were more than three times more
likely than nonHIV-infected women to have prolonged
amenorrhea without ovarian failure (94).
Low bone mineral density has been found to be more
prevalent among women with HIV approaching menopause than those without HIV infection (95). Even among
women with normal bone mineral density, a casecontrol
population-based study showed that HIV-infected women
reported significantly more osteoporotic fractures than
women in the control group (96). Data regarding treatment of osteoporosis for HIV-infected women are lacking.
Standard suggestions for treatment and prevention can
be made, including increasing physical activity, stopping
smoking, and taking calcium and vitamin D supplements.
Small studies confirm the benefits and safety of alendronate therapy in HIV-infected patients (97).
How should HIV-infected women be counseled

about transmission prevention?
The most effective method of avoiding sexual transmission of HIV infection is abstinence from sex (or in the
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case of HIV-negative women, limiting sexual contact to

a mutually monogamous uninfected partner). A metaanalysis showed that consistent use of male condoms
resulted in an 80% reduction in the risk of HIV transmission among HIV serodiscordant couples, and should be
recommended for the prevention of HIV transmission
as well as other STIs (98). Condom use also should be
promoted as an adjunctive method to decrease the risk of
transmission of HIV in women using other methods of
contraception. Efficacy of female condoms in reducing
the risk of HIV transmission remains to be demonstrated
(99). Laboratory studies indicate that the female condom
is an effective mechanical barrier to viruses, including
HIV (100). However, a limited number of clinical studies
has evaluated the efficacy of female condoms in providing protection from STIs, including HIV (101).
Although reported rarely, it is possible that continued sexual exposure to a partner with an elevated viral
load may adversely affect the viral load of a patient taking HAART, and may lead to superinfection. Therefore,
the couples where both partners are HIV infected should
be counseled that condoms should be used to decrease
the potential risk of superinfection.
Vaginal spermicides containing nonoxynol-9 are not
effective in preventing HIV infection and may, in fact,
increase the risk of HIV transmission secondary to associated disruption of the genital epithelium (102). Women
with HIV should be screened and treated for genital
infections because numerous studies have demonstrated
that genital ulcer disease, cervical infections, and vaginal
infections increase HIV shedding in the female genital
tract and that successful treatment reduces shedding
(103). In an observational study, HAART was reported
to decrease the risk of heterosexual HIV transmission up
to 80% among serodiscordant couples (104). However,
because HIV can be detected in the semen, rectal secretions, female genital secretions, and pharynx of HIVinfected patients with undetectable plasma viral loads
and because consistent reduction of viral load depends on
close adherence to antiretroviral regimens, HIV-infected
women, even those with undetectable plasma loads,
should be counseled that they can still transmit HIV
(105). Observational studies indicate that antiretroviral
postexposure prophylaxis may reduce the risk of HIV
infection if initiated within 72 hours of sexual exposure
to an HIV-infected partner (106).
Clinicians should screen HIV-infected women for
behavioral risk factors for transmission at least annually
and more often if indicated (eg, if a woman has a new STI)
(105). Innovative and successful interventions (emphasizing cognitive theory and the theory of gender and
power) to decrease risk taking by HIV-infected patients
have been developed for diverse populations (107). For
example, a trial (among heterosexual nonHIV-infected

patients at STI clinics) found that two 20-minute
enhanced counseling sessions (Project RESPECT) led to
increased self-reported condom use and decreased rate
of incident STIs compared with patients who received
didactic messages only (108). The underlying principle
of providing effective risk-reducing counseling is to
individualize the message provided to the patient receiving the counseling. Behavioral interventions targeting
adult and adolescent women of color are crucial to
decrease rates of morbidity and mortality from HIV and
AIDS (2).
What methods of contraception are the most

effective for women with HIV and what
methods are contraindicated?
Women infected with HIV require highly effective contraception that is compatible with HAART regimens (if
applicable), places them at low risk of acquiring STIs,
and does not increase their risk of transmitting HIV to
their partners (Table 1 and Table 2).
Hormonal contraception is safe in women with HIV.
Two prospective cohort studies have assessed the safety
of hormonal contraception among HIV-infected women.
Postpartum HIV-infected Kenyan women using oral
contraceptives (OCs) or depot medroxyprogesterone
acetate (DMPA) showed no differences in HIV RNA
load or absolute levels or a decrease in CD4 count compared with those of women not using hormonal contraception (109). In the Womens Interagency HIV Study,
HIV-infected U.S. women using hormonal contraception
(OCs, DMPA, or progestin contraceptive implant) had
similar HIV RNA levels and minor increases in CD4
count compared with women not using hormonal contraception (110).
For women using HAART, there are some concerns regarding the efficacy of hormonal contraception.
Hormonal contraceptives are primarily metabolized
via sulphate and glucoronide conjunction in the liver
and also are metabolized through cytochrome P450
enzymes. Human immunodeficiency virus antiretroviral
agents have varying effects on these metabolic pathways (Box 2). The data on the interactions of specific
hormonal contraceptives and HIV antiretroviral agents
is limited and type specific. For women taking certain
HAART regimens, combined OCs generally are not
recommended because of potential alterations in the
hormonal contraceptive and the antiretroviral drug (111,
112). Specifically, for women taking ritonavir-boosted
protease inhibitors, combined OCs generally are not
recommended due to potentially decreased efficacy of
the contraceptive (112, 113). Also, the nonnucleoside
reverse transcriptase inhibitor nevirapine reduced levels

of combined OCs (ethinyl estradiol and norethindrone)
when coadministered (114). But women taking nonritonavir-boosted atazanavir or indinavir, or using the nonnucleoside reverse transcriptase inhibitor efavirenz may
be able to use combined OCs without a loss of efficacy
(111). Up-to-date information regarding drug interactions with antiretroviral agents can be found at http://
hivinsite.ucsf.edu/insite?page=ar-00-02 and http://www.
hiv-druginteractions.org.
Generally, the U.S. Department of Health and Human
Services recommends additional or alternative (non-oral
hormonal) contraception for HIV-infected women taking
most nonnucleoside reverse transcriptase inhibitors or
protease inhibitors and recommends against coadministering combined OCs with fosamprenavir secondary to a
decrease in the blood level of the antiretroviral agent when
coadministered (6). The Centers for Disease Control and
Prevention advises the use of condoms if combined OCs
are used in combination with antiretroviral therapy (112).
Depot medroxyprogesterone acetate was found to have no
interactions with several antiretroviral agents, including
efavirenz, nevirapine, and nelfinavir, and is considered
safe and effective for use by HIV-infected women (115,
116). No studies have examined the interaction of other
types of hormonal contraception (eg, subdermal implant,
vaginal ring, and contraceptive patch) with antiretroviral
agents, so the same precautions as used with combined
OCs are recommended.
Intrauterine devices (IUDs) are a good contraceptive method for HIV-infected women. A randomized
study showed the copper IUD is safe and effective for
use in HIV-infected women, with a higher rate of efficacy compared with combined OCs, and was associated
with only one case of PID (0.16 cases per 100 womanyears) (117). A prospective cohort study showed no
association between HIV infection and complications
in the first 2 years of using a copper IUD (118). The
copper IUD was not associated with increased HIV-1
viral shedding measured 4 months after insertion in
a single study (119). Data regarding the use of the
levonorgestrel-containing IUD are more limited, but a
small observational study of HIV-infected women using
the levonorgestrel-containing IUD showed a reduction
in menstrual blood loss, with no adverse effects on CD4
count or cervical cytology screening test results (120).
Another small study showed no known drug interactions
between the levonorgestrel-containing IUD and HAART
and no increase in genital shedding of HIV RNA (121).
Based on some of these studies, the CDC currently
recommends that for women at high risk of HIV acquisition, HIV-infected women, HIV-infected IUD users
converting to an AIDS diagnosis, and women with AIDS
Practice Bulletin
Table 1. Summary of Risk Classifications for the Use of Hormonal Contraceptive Methods and Intrauterine Devices
Condition
Combined
Hormonal
Contraceptive:
Oral, Patch, Progestogenand Ring
Only Pill
DMPA
Implants
LevonorgestrelContaining IUD
Copper IUD
Initiation Continuation
Initiation Continuation
HIV and AIDS

High risk of HIV infection
HIV infection
AIDS
Clinically well on
antiretroviral therapy
If taking antiretroviral therapy, refer to the section

on Antiretroviral Therapy
Antiretroviral Therapy
Nucleoside reverse
transcriptase inhibitors
2/3
2/3
Nonnucleoside reverse
transcriptase inhibitors
2/3
2/3
Ritonavir-boosted
protease inhibitors
2/3
2/3
AIDS indicates acquired immunodeficiency syndrome; DMPA, depot medroxyprogesterone acetate; HIV, human immunodeficiency virus; IUD, intrauterine device.
Categories of Medical Eligibility Criteria for Contraceptive Use
1 = A condition for which there is no restriction for the use of the contraceptive method
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
4 = A condition that represents an unacceptable health risk if the contraceptive method is used
Farr S, Folger SG, Paulen M, Tepper N, Whiteman M, Zapata L, et al. U.S. medical eligibility criteria for contraceptive use, 2010: adapted from the World Health
Organization Medical eligibility criteria for contraceptive use, 4th edition. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion; Centers for Disease Control and prevention (CDC), MMWR Recomm Rep 2010;59(RR-4):186. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf.
Retrieved July 27, 2010.
who are clinically well while taking HAART, the copper

and levonorgestrel-containg IUDs may be used (112).
Recommendations for sterilization of HIV-infected
women are no different than those for nonHIV-infected
women. As with other medical conditions, consideration
should be given to optimizing a patients health status
before elective surgery.
In addition to methods to avoid unintended pregnancy, women with HIV should be counseled regarding
the need to protect themselves from STIs and to prevent
HIV transmission to uninfected partners. Although
condoms are the only effective method of avoiding
transmission of infection with sexual intercourse, they
are not a particularly effective method of contraception,
with a typical failure rate of 15% over 1 year. Therefore,
patients should be counseled that dual contraception (ie,
the concomitant use of condoms and additional contraception) is the optimal contraceptive strategy to reduce
heterosexual transmission of HIV and other STIs as
well as minimizing the risk of unintended pregnancy.
1500
Practice Bulletin
However, studies have shown that the more effective

the other method is for pregnancy prevention, the less
likely women and their partners are to combine it with
condoms (122). Therefore, one strategy may be to use
condoms as their primary method of birth control and of
disease prevention, with emergency contraception as a
backup to increase contraceptive efficacy.
How should patients planning to become

pregnant be counseled in order to achieve
optimal maternal and fetal health?
The advent of HAART and the reduction of motherto-child transmission of HIV over the past decade to
achievable rates of less than 1% have allowed HIVinfected women to live longer and healthier lives and
to have more fertility options. A cohort study reported
that HIV-infected women have similar reproductive patterns as nonHIV-infected women, with most already
having children and many wanting children in the future
Table 2. Summary of Risk Classifications for the Use of Barrier Methods of Contraception
Method
Condition
Condom
Spermicide
Diaphragm
Comments
High risk of HIV
Repeated and high-dose use of the spermicide

nonoxynol-9 was associated with increased risk
of genital lesions, which may increase the risk
of HIV infection*.
Diaphragm use is assigned Category 4 because
of concerns about the spermicide, not the
diaphragm.
HIV Infection
Use of spermicides or diaphragms (with

a spermicide) can disrupt the cervical mucosa,
which may increase viral shedding and HIV
transmission to uninfected sex partners.
AIDS
Use of spermicides or diaphragms (with

a spermicide) can disrupt the cervical mucosa,
which may increase viral shedding and HIV
transmission to uninfected sex partners.
AIDS indicates acquired immunoeficiency syndrome; HIV, human immunodeficiency virus.

Categories of Medical Eligibility Criteria for Contraceptive Use
1 = A condition for which there is no restriction for the use of the contraceptive method
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
4 = A condition that represents an unacceptable health risk if the contraceptive method is used
*Wilkinson D, Ramjee G, Tholandi M, Rutherford G. Nonoxynol-9 for preventing vaginal acquisition of HIV infection by women from men. Cochrane Database of
Systematic Reviews 2002, Issue 3. Art. No.: CD003936. DOI: 10.1002/14651858.CD003936.
Farr S, Folger SG, Paulen M, Tepper N, Whiteman M, Zapata L, et al. U.S. medical eligibility criteria for contraceptive use, 2010: adapted from the World Health
Organization Medical eligibility criteria for contraceptive use, 4th edition. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion; Centers for Disease Control and prevention (CDC), MMWR Recomm Rep 2010;59(RR-4):186. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr5904.pdf.
Retrieved July 27, 2010.
(123). The Womens Interagency HIV Study cohort

study showed that after HAART became available, the
live birth rate among HIV-infected women was 150%
higher compared with only 5% higher among similar
nonHIV-infected women during the same period (124).
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.
Similar to preconception counseling for nonHIVinfected women, the goals for HIV-infected women are
to improve the health of the women before conception
and to identify risk factors for adverse maternal and
fetal outcomes. Safe sex practices and avoidance of STIs
should be discussed. Risky behaviors, such as smoking
and substance abuse, should be reduced and the use of
folic acid before conception should be recommended.
Overall health should be optimized, and health care
should be coordinated with other health care providers to
ensure that hepatitis A, hepatitis B, pneumococcal, and
influenza vaccinations have been provided as recommended by the CDC (125).
Preconception counseling of HIV-infected women

should include a detailed discussion of interventions to
reduce the risk of mother-to-child transmission, ways to
optimize their long-term health, and the possible effects
of antiretroviral medications on the fetus. For women
taking HAART, attainment of a stable, maximally suppressed viral load before conception is recommended
(126). 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. Efavirenz is the only antiretroviral agent with a strongly suggested teratogenic
risk, and it should be avoided in the first trimester (7).
Therapy-associated side effects (eg, hyperglycemia,
anemia, and hepatic toxicity) that can affect maternal
fetal health also should be considered. All HIV-infected
women considering pregnancy should be counseled
regarding the availability of measures to decrease the
risk of vertical transmission of HIV, including treating
all HIV-infected pregnant women with HAART with
the goal of reaching undetectable HIV RNA levels at
the time of delivery, cesarean delivery for HIV-infected
Practice Bulletin
Box 2. Oral Contraceptives and

Antiretroviral Therapy
Antiretroviral Agents That Decrease Hormone Levels
Ritonavir, nelfinavir, lopinavir4050% decrease
in ethinyl estradiol levels. Alternative or additional
method of contraception should be used.
Amprenavirdecrease in ethinyl estradiol and norethindrone levels. Because the oral contraceptive
agents decrease the amprenavir levels by 20%, the
agents should not be coadministereded and an alternative method of contraception should be used.
Nevirapine20% decrease in ethinyl estradiol levels.
Alternative or additional method of contraception
should be used.
Antiretroviral Agents That Increase Hormone Levels
Efavirenz37% increase in ethinyl estradiol levels;
clinical significance unknown. Alternative or additional method of contraception should be used.
Atazanavir48% increase in ethinyl estradiol levels
and 110% increase in norethindrone levels. The lowest effective dose or alternate method of contraception should be used.
Data from Anderson JR. Approach to the patient. In: Anderson JR,
editor. A guide to the clinical care of women with HIV. Rockville
(MD): Health Resources and Services Administration; 2005. p.
35 46.
women failing to achieve viral suppression of a CD4

count of less than 1,000 cells per cubic millimeter,
avoidance of breastfeeding, and providing newborns
with prophylactic antiretroviral medications for several
weeks (127).
Methods to prevent transmission of HIV to uninfected partners also should be discussed. For an HIV-infected
woman in a discordant relationship who wishes to conceive, insemination of her partners sperm at the time
of ovulation will avoid HIV transmission risk through
unprotected intercourse.
For discordant couples in which the male is HIVinfected, assisted conception with either sperm washing
for insemination or intracytoplasmic sperm injection
(ICSI) may be safer than timed unprotected intercourse
with regard to HIV transmission (128). Donor insemination with sperm from a nonHIV-infected male remains
the safest option to avoid transmission. In a prospective
study conducted before HAART therapy was available,
the authors studied discordant couples trying to conceive
through unprotected intercourse limited to the fertile
period of the womans cycle; 4% of women seroconverted (129). In a retrospective study of 62 discordant
1502
Practice Bulletin
couples in Spain, in which the infected partner had suppressed HIV replication (less than 500 HIV copies per
milliliter) and used HAART therapy before conception,
no transmissions were observed (130). Sperm washing
is a potential way to conceive while reducing the risk
of infection to the HIV-negative woman. In reports of
more than 3,000 cycles of sperm washing combined with
intrauterine insemination, in vitro fertilization, or ICSI,
no cases of seroconversion in either female partner or
offspring have been reported (131, 132).
The American Society of Reproductive Medicine
Ethics Committee recommends that fertility services be
offered to HIV-infected individuals and couples willing
to use risk-reducing therapies to the extent that it is economically and technically feasible. They further recommend that when an affected couple requests assistance
to have their own genetically related child, they are best
advised to seek care at institutions with the facilities that
can provide the most effective evaluation treatment and
follow-up (133). However, some state laws ban assisted
conception with HIV-positive sperm, and the CDC
continues to discourage the use of washed semen from
HIV-infected partners (134, 135). Costs associated with
advanced reproductive techniques, such as in vitro fertilization and ICSI, may limit access for some couples. In
addition, two more recent studies reporting no HIV transmission using washed sperm with intrauterine insemination have led many experts to recommend consideration
be given to this approach (132, 136).
Summary of
Recommendations and
Conclusions
The following recommendation is based on good
and consistent scientific evidence (Level A):
Condoms are recommended for the prevention of
HIV transmission as well as other STIs.
The following recommendations and conclusions

are based on limited or inconsistent scientific
evidence (Level B):
The American College of Obstetricians and Gynecologists recommends routine HIV screening of
women aged 1964 years and targeted screening for
women with risk factors outside of that age range.
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).
Human papillomavirus testing currently has no role

in the triage of HIV-infected women with abnormal
cytology results or for follow-up after treatment for
CIN.
For women at high risk of HIV acquisition, HIVinfected women, HIV-infected IUD users converting
to an AIDS diagnosis, and women with AIDS who
are clinically well while taking HAART, the copper
and levonorgestrel-containing IUDs may be used.
Women with HIV infection should have cervical
cytology screening twice in the first year after diagnosis of HIV and annually thereafter.
Routine colposcopy is recommended for HIV-infected
women with ASC-US or higher grade abnormality.
The following recommendations are based primarily on consensus and expert opinion (Level C):
Patients should be counseled that dual contraception
(ie, the concomitant use of condoms and additional
contraception) is the optimal contraceptive strategy
to reduce heterosexual transmission of HIV and
other STIs as well as minimizing the risk of unintended pregnancy.
For women taking certain HAART regimens, combined OCs generally are not recommended because
of potential alterations in the hormonal contraceptive
and the antiretroviral drug as outlined in Box 2.
Reproductive plans, including preconception counseling and counseling regarding reversible methods
of contraception, if appropriate, should be discussed
with HIV-infected women of childbearing age.
Repeat cytologic testing at 6 months and 12 months
is recommended for HIV-infected women with mild
cytologic abnormalities, satisfactory colposcopy results,
and no evidence of histologic high-grade disease.
Couples where both partners are HIV infected should
be counseled that condoms should be used to decrease
the potential risk of superinfection.
Resources
U. S. Department of Health and Human Services
Drug and Food Information
http://www.aidsinfo.nih.gov/DrugsNew/Default.aspx

Tool Kit for Teen Care, Second Edition
http://www.acog.org/departments/adolescentHealthCare/
TeenCareToolKit/ACOGPreventCare.pdf
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The MEDLINE database, the Cochrane Library, and the

own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985April 2010. The search was
restricted to articles published in the English language.
Priority was given to articles reporting results of original
research, although review articles and commentaries also
were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate
for inclusion in this document. Guidelines published by
organizations or institutions such as the National Institutes
of Health and the American College of Obstetricians and
Gynecologists were reviewed, and additional studies were
located by reviewing bibliographies of identified articles.
When reliable research was not available, expert opinions
from obstetriciangynecologists were used.
Studies were reviewed and evaluated for quality according
to the method outlined by the U.S. Preventive Services
Task Force:
I
Evidence obtained from at least one properly
designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
casecontrol analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level ARecommendations are based on good and consistent scientific evidence.
Level BRecommendations are based on limited or inconsistent scientific evidence.
Level CRecommendations are based primarily on consensus and expert opinion.
Copyright December 2010 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this
publication may be reproduced, stored in a retrieval system,
posted on the Internet, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording, or
otherwise, without prior written permission from the publisher.
Requests for authorization to make photocopies should be
directed to Copyright Clearance Center, 222 Rosewood Drive,
Danvers, MA 01923, (978) 750-8400.
The American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
Gynecologic care for women with human immunodeficiency virus.
Practice Bulletin No. 117. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2010;117:14921509.
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THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS

WOMEN S HEALTH CARE PHYSICIANS

NUMBER 117, DECEMBER 2010

Gynecologic Care for Women With

Antiretroviral Therapy for Nonpregnant

is optimal to address both the medical and social

VOL. 116, NO. 6, DECEMBER 2010

OBSTETRICS & GYNECOLOGY

not be used as a component of combination therapy in

Box 1. Conditions Defining Acquired

Clinical Considerations and

approved antiretroviral agents from six medication

VOL. 116, NO. 6, DECEMBER 2010

Are injection drug users

Gynecologic Care for Women With HIV 1493

that informing infected individuals who are unaware of

specificity of 99.7% (14). Human immunodeficiency

How are recommendations for cervical

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OBSTETRICS & GYNECOLOGY

VOL. 116, NO. 6, DECEMBER 2010

In nonpregnant women aged 21 years and older, both

Gynecologic Care for Women With HIV 1495

In HIV-infected women, how does diagnosis

nosis, but these results were primarily thought to occur

In HIV-infected women, how do diagnosis

Gynecologic Care for Women With HIV

OBSTETRICS & GYNECOLOGY

with more frequent screening if indicated by symptoms

VOL. 116, NO. 6, DECEMBER 2010

In HIV-infected women, how does treatment

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In HIV-infected women, how do the diagnosis

How should HIV-infected women be counseled

case of HIV-negative women, limiting sexual contact to

Gynecologic Care for Women With HIV

OBSTETRICS & GYNECOLOGY

example, a trial (among heterosexual nonHIV-infected

What methods of contraception are the most

VOL. 116, NO. 6, DECEMBER 2010

reverse transcriptase inhibitor nevirapine reduced levels

Gynecologic Care for Women With HIV 1499

HIV and AIDS

If taking antiretroviral therapy, refer to the section

who are clinically well while taking HAART, the copper

However, studies have shown that the more effective

How should patients planning to become

Gynecologic Care for Women With HIV

OBSTETRICS & GYNECOLOGY

High risk of HIV

Repeated and high-dose use of the spermicide

Use of spermicides or diaphragms (with

Use of spermicides or diaphragms (with

AIDS indicates acquired immunoeficiency syndrome; HIV, human immunodeficiency virus.

(123). The Womens Interagency HIV Study cohort

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Preconception counseling of HIV-infected women

Gynecologic Care for Women With HIV 1501

Box 2. Oral Contraceptives and

women failing to achieve viral suppression of a CD4

The following recommendations and conclusions

Gynecologic Care for Women With HIV

OBSTETRICS & GYNECOLOGY

Human papillomavirus testing currently has no role