HIV in Gynaecology

 16-18% HIV prevalence in Zimbabwe

 Majority are asymptomatic
 Majority not aware of HIV status
 Stigma attached to HIV/AIDS and
insensitivity reduces management of patients
 General management of HIV requires a team
approach
Risk factors for HIV infections
 Unprotected sex
 Increased number of sex partners
 History of sexually transmitted infections
 History of illicit drug use
 History of alcohol abuse
 Promiscuous sex partner
Epidemiology of HIV in women
  50% of new infections in women
 Women infected at higher rates and
younger ages in Sub Saharan Africa
 Seroprevalence ranges from 10-30% in
sexually active women
Risk Factors for Infection in Women

 Male-to-female transmission of HIV I is more

efficient than female to male transmission (2-17
times higher)
 Sexually transmitted Diseases
 Intravenous Drug Use
 Role of Contraception still unclear
 Severity of Disease in partner
Women and HIV
 Social risk factors
 Illiteracy
 Lack of awareness of preventive measures
 Biological risk factors
 Twice as easy for women to contract HIV from men
 Physiology of women (e.g. menstruation, intercourse)
 Pregnancy-associated conditions (e.g anemia,
menorrhagia and haemorrhage) increase the need for
blood transfusion.
Gynaecological conditions associated with HIV
infections
 Abnormal Pap smears
 HPV infection
 Invasive cervical cancer
 Genital ulcers
 Vaginal infections
 Pelvic Inflammatory Disease
 Other HIV associated neoplasms such as Kaposi
Sarcoma
Genital tract infections increase susceptibility
 Genital ulcer disease (gonococcal & chlamydial
infections: 2 to 4 times risk of infection)
 Candida and trichomoniasis: 2 – 3 times risk
 Bacterial vaginosis – 3 times risk
 Syndromic management of STDs decreases risk of
HIV acquisition
 Consistent male and female condom use reduces risk
of HIV acquisition by 7 – 8 fold
Vaginal discharge
 Commonest infections are
 Bacterial vaginosis: 18 – 42% prevalence in HIV
positive may enhance HIV transmission.
 Vulval candidiasis – increasing infection rates with
declining CD4 counts
 Trichomoniasis: 5 – 25% prevalence
 Gonococcal and chlamydia infections not
significantly affected by HIV but known to be co-
factors for incident HIV infection.
Pelvic Inflammatory Disease
In HIV positive women:
 Increased prevalence of PID in hospitalized women

 Endometritis twice as common

 More severe illness, longer hospital stays, more

recurrence of abscesses, more repeat surgery
 Similar microbiology and antibiotic treatment
Genital ulcer disease
 HSV2 is the most prevalent GUD in Zimbabwe in all women
HIV positive patients :
 More frequent, prolonged and severe episodes are common
with lesions sometimes atypical
 Viral shedding increases with the declining CD4 count

 HSV is associated with increased risk or HIV transmission

and acquisition
 Need higher doses, longer treatment courses with acyclovir
and may benefit from suppressive therapy.
Genital ulcer disease (cont.)

 Daily suppressive therapy eg Acyclovir 400mg bd

reduces recurrences and viral shedding
 Clinical presentation of syphilis may be atypical
 All other causes of GUD: chancroid,, LGV,
Granuloma ,TB may require longer and more
complex treatment.
Cervical dysplasia
 In HIV positive patients 30 – 60% of Pap smears are
abnormal
 15 – 40% have dysplasia
 Rates of dysplasia are 10 times greater than in HIV
negative women
 HIV infected women have higher HPV prevalence,
longer persistence of HPV, more HPV subtypes,
greater prevalence of oncogenic subtypes
 Clinically expressed HPV infection is doubled
HIV and cervical cancer
 HIV positive women should have more frequent
cervical cancer screening
 More frequent follow up following treatment of pre-
invasive disease
 Lower threshold for colposcopy in HIV positive
women
 The entire lower genital tract (vagina, vulva,
perineum, cervix) should be evaluated at colposcopy
Invasive cervical cancer
 Invasive cervical cancer is now considered an AIDS defining
condition
 AIDS surveillance data show increasing rates of cancer in
HIV positive women
 Higher prevalence of cancer in women 20 – 34 years who are
HIV positive
 Women with HIV and cervical cancer tend to be younger,
less immunosuppressed
 HIV positive women tend to present with cancer at more
advanced stages, metastases to unusual sites (e.g. psoas
muscle, clitoris, meninges) have poor response to treatment,
higher recurrence rates and death rates.
Clinical Manifestations of HIV in
Women
 Higher rates of bacterial pneumonia than
men
 Lower rates of Kaposi Sarcoma than men
 Higher rates of cervical dysplasia
 Recurrent vaginitis
Malignancies associated with HIV infection
 40% of people with HIV infection have cancer as a
cause of death or morbidity
 Increase CIN and faster rates of progression and
more recurrent lesions.
 A strong association with invasive cervical cancer
has not yet been demonstrated but strong association
with HPV natural history indicates correlation
Disease progression and overall survival
 Older age, asymptomatic disease and low CD4
counts at initial study are the main determinants of
survival.
 Injection drug use, race, ethnicity, gender are not
predictive of survival
 Overall time to onset of AIDS in infected adults is
10 years (USA)
 After diagnosis of AIDS median survival in those
not on antiretrovirals is 22 – 26 months
Gynaecological AIDs defining
Conditions

 Persistent HSV lasting >1 month

 Kaposi sarcoma of vulva
 Pelvic TB
 Invasive cervical cancer
Family planning for HIV infected women
Counselling should include discussion of:-

 Risk of HIV transmission to partner or foetus

 Range of available methods
 Available support in community for the woman’s
reproductive decisions.
Choice of contraception
 No single agent provides ideal contraception as well
as protection against STD.

 Combination of barrier methods and hormonal or

permanent methods is the best available
contraception.

 Concurrent treatment e.g antituberculosis agents and

antiretrovirals may decrease contraceptive efficacy.