Pocket ObGyn – HIV / AIDS in Women

Dec 9, 2019 admin NHIỄM KHUẨN, PHỤ KHOA 0

Pocket ObGyn – HIV / AIDS in Women
See Abbreviations

Definition & Epidemiology
  • AIDS: HIV infxn w/ or w/o sx + CD4 count <200/mm3 or AIDS-indicator condition (OI or AIDS-related malig).
  • Caused by infxn w/ HIV-1 or HIV-2 Female infxn in US = 23% of cases (PLoS ONE 2011;6:e17502). 2/3 heterosexual transmission. Risk factors: Minority ethnicity (AA ® 10´ ­ infxn, & leading cause of death for AA  25–34 yo); low socioeconomic status; urban location (JAMA 2001;285:1186).
Pathophysiology
  • HIV RNA virus targets CD4 receptor on T-lymphocytes
  • Destruction & impairment of CD4 cells ® immunodeficiency ® OIs thrive
  • Monit dz progression & resp to rx w/ CD4 count & viral RNA-load
  • Potentiation of transmission by other Infxn w/ STI ­ HIV risk 2–5´ due to ­ viral shedding, genital mucosal disruption, & local recruitment of inflamm cells (Curr Opin HIV/AIDS 2010;5:305); includes HSV, BV, trichomonas, gonorrhea/chlamydia & HPV

Gynecologic Care (Obstet Gynecol 2010;116:1492)

  • HIV screening recommended: IV drug use, HIV+ sex partner, STI dx, prostitution, multi sex partners, Preg
  • 1st-step screening by ELISA ® Western blot for band specific confirmation
  • HIV+ ® ­ number & severity of vaginal infections ® screen frequently for other STIs
  • Clinical course differs w/ HIV HSV ® ­ frequency, pain, duration; use HSV suppression ppx. Syphilis ® ­ neurosyphilis & rx failure; re-evaluate clinically & w/ serologic titers at 3, 6, 9, 12, & 24 mo after therapy (CDC MMWR 2010;59:No.RR-12)
  • Latex condoms are the only contraceptive that reduces HIV transmission; spermicides do NOT reduce
  • HAART recommended for all HIV-infected individuals
  • ¯ OCP efficacy w/ PIs & NNRTIs. Long-acting reversible contraception (IUD, implant) safe &
  • HIV+  6´ greater odds of ¯ bone mineral density & 4´ ­ odds of osteoporosis
  • ­ incid of abn cervical 4–6´ ­ risk for CIN. HPV infxn = 65% in HIV+ women vs. 30% seronegative (JAMA 2000;283:1031; Glob Libr Women’s Med 2009;10:3843) w/ ­ HPV persistence & progression. Incid of CIN correlates w/ ¯ CD4 count & ­ HIV RNA levels. Routine colposcopy not recommended.
  • Cervical cancer ­ due to behavioral (less screening, IV drug use) & biologic factors (immunosuppression). More likely to present at advanced clinical
  • VIN,VAIN, & AIN also ­ in HIV+ women (Obstet Gynecol 2006;107:1023)
  • HAART a/w ¯ prevalence, ¯ incid & ­ clearance of SIL (J Inf Dis 2010;201:681)

HIV in Pregnancy (http://aidsinfo.nih.gov/guidelines)

  • Univ routine testing (opt-out) for all pregnant women at initial prenatal Women who present in labor w/o prenatal care should get rapid HIV test; intrapartum AZT ¯ perinatal transmission. HIV a/w SGA, preterm deliv.
  • Due to Preg plasma vol changes, CD4 count ¯ but no change on CD4 Dz progression unusual Preg (J infect Dis 1992;165:1116)
  • HIV+ women should get pneumococcal, influenza, hepatitis A (if nonimmune), & hepatitis B vaccines + other std Preg Screen for hepatitis C, given high rates of coinfection (MMWR Recomm Rep 2009;58:1).
  • Transmission can occur transplacentally (related to mat viral load), during deliv, & w/ breastfeeding (N Engl J Med 1999;341:1698). HAART can ¯ perinatal transmission to <1% (untreated 15–25%) (N Engl J Med 1994:331:1173). Start HAART during Preg to suppress viral load, continue ppx at deliv, & provide neonat ppx to the
  • Transmission rates: HAART < dual therapy < AZT monotherapy << no therapy

Antepartum: All women should receive HAART during Preg – generally a combination from at least 2 classes of drugs. Recommended regimen is Zidovudine/ Lamivudine/Ritonavir/Lopinavir. Efavirenz (NNRTI) category D: A/w increased neural tube defects. Some women may opt to start HAART after 1st trimester & organogenesis.

Intrapartum AZT mgmt: AZT at onset of labor 2 mg/kg loading dose followed by 1 mg/kg/h until deliv. Optional for women on HAART w/ HIV viral load <400 copies/mL. Continue oral HAART intrapartum. Avoid artificial rupture of membranes & instrumentation (scalp electrodes, operative deliv) if poss.

Postpartum: Infants should receive AZT for 6 w. Infants born to mothers not on HAART should receive 3 doses of nevirapine. Mat HAART continuation is essent given high rates of nonadherence & subseq mortality postpartum.

Mode of deliv: CD ¯ transmission rates in women NOT receiving HAART & zidovudine monotherapy (2–4´). No signif difference in transmission rates btw CD & VD in women on HAART. CD indicated if viral load >1000 copies/mL. 3 h of AZT should be administered prior to operation if poss. Duration of ROM a/w transmission in women w/ unsuppressed viral load ® best to perform CCD prior to ROM or active labor.

Breastfeeding not recommended in developed countries even when mother on HAART, due to postnatal transmission risk (MMWR Morb Mortal Wkly Rep 1985;34:721). Rate of HIV transmission ~10% from breastfeeding, but varies based on mat CD4 count, HIV viral load, & HAART use. In developing world, do recommend breastfeeding b/c infant mortality from HIV offset by increased diarrheal & PNA illness in formula-fed infants (JAMA 2006; 296:794).

See Abbreviations

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