Clinical:Case Study: Women and HIV Part II - Next Steps

Original materials created in July 2002 by Suzanne Eidson-Ton, M.D.

This case is the second in a two-part series designed to touch on some of the important issues to consider when caring for a woman with HIV/AIDS. Like Part I, “Women and HIV, Part II” provides an overview, rather than details, of care for women with HIV infection in order to acknowledge the complexity and the wide-reaching effects of the virus on every body system, and the patient’s experience of life. Again, provider resources are included at the conclusion of the case.

Women and HIV Part II: Next steps

Brief history: AD was introduced to us in last month’s In This Case as a 38 yo patient of Dr. Eidson-Ton’s who was being seen for amenorrhea, and was subsequently discovered to have acquired HIV through heterosexual intercourse. AD’s physical exam was normal, except for an asymptomatic vaginal yeast infection, and her studies revealed only mild anemia. She has been in a monogamous relationship for almost one year with a man whose risk status was unknown.

Discussion

Last month, Dr. Eidson-Ton discussed the epidemiology of HIV/AIDS in the United States, transmission of HIV in women, and domestic violence and HIV infection. Her discussion and plan continue below.

Pregnancy and HIV Like AD

Many women find themselves diagnosed with HIV as part of the pre-natal work-up because pregnancy and HIV are transmitted jointly through unprotected heterosexual activity. This situation raises a host of emotional, ethical, and biomedical issues. Women must make many complex decisions, beginning with whether to continue their pregnancies or not. Women carrying pregnancies to term must decide on antepartum, intrapartum and neonatal use of potentially teratogenic medications, in an attempt to prevent transmission of HIV to the baby. Prophylactic cesarean sections to prevent transmission are controversial and represent another of the many choices that women must make. ^[1]

Opportunistic Infections and Comorbidities Many opportunistic infections are similar in men and women, and many are different. In the US, for example, Karposi’s sarcoma seems to be a disease largely of men; Candida esophagitis may occur at higher CD4 counts in HIV-infected women than in men. Many other examples of differences exist, and more research is needed with women subjects to confirm trends in infections at various CD4 counts, and appropriate treatments.

Gynecologic issues are of particular importance to women with HIV. 1) The virulence of human papilloma virus (HPV) in causing cervical cancer is related to the immune-competence of the host. Therefore, women with HIV are at high risk of cervical dysplasia, particularly with CD4 counts less than 200. Many MD’s recommend that women with HIV should undergo baseline colposcopy even in the setting of a normal pap smear and repeat pap and/or colposcopy every 6 months. HIV positive women should also undergo more aggressive follow- up for abnormalities noted on the pap smear; 2) Vaginal candidiasis: While symptomatic vaginal yeast infections are not necessarily more common in HIV-positive women, candidal colonization is increased. Women with symptomatic infections may have recurrent or difficult to treat non-albicans species. Consider topical terconazole, as it may treat non-albicans, and fluconazole orally. Rarely, for resistent species, low-dose amphotericin B may be used. Women with HIV may need suppressive therapy as well; 3) HIV positive women who have PID are more likely to develop tubo-ovarian absesses (up to 1/4 of those with PID and HIV); 4) Herpes simplex infections may be more recurrent and or severe in women with HIV; and 5) Menstrual irregularities, particularly amenorrhea occur in women with HIV; although, this may be related to lower serum albumin levels and/or concurrent drug use. ^[2]

Plan

When asked, HIV-infected women have reported that the most important part of the provider- patient relationship in HIV care is a nonjudgmental attitude on the part of the provider. Many providers may find this challenging with patients who have used drugs, traded sex for money or drugs, or had multiple sex partners, requiring a shift of attitudes. I kept this in mind as AD and I had a long discussion regarding her HIV+ status, modes of transmission, disease course and AIDS, and treatment options.

I had already screened AD, and knew she was not at risk for violence in her relationship, so I counseled AD to discuss her HIV status with her partner. I offered to see them both in the office for the discussion, if she preferred. I stressed safer sex and the use of condoms in the case of continued sexual relations to prevent re-infecting each other, and undermining treatment.

We agreed to enlist an HIV/AIDS specialist to work with us on an anti-retroviral treatment regimen, and in particular, when to begin HAART (highly active anti-retroviral treatment), as well as when to be prophylaxis against opportunistic infections. We checked a CD4 count and viral load. AD eventually underwent colposcopy, ruling out significant HPV disease. She was counseled on the necessity for regular pap smears. We did not treat AD’s asymptomatic yeast colonization.

Additional important interventions at this time include referral for life-style and nutrition counseling, smoking cessation, psychological counseling depending on AD’s need, and referral to social service agencies in AD’s area that provide services to women with HIV. Further, referral to an HIV support group (or WORLD—see below) would be an excellent way for AD to learn more about her disease and come to terms with the changes in her life she will inevitably experience as a result of it.

References

1. ↑ “Public Health Service Task Force Recommendations for the Use of Antiretroviral Drugs in Pregnant Women Infected with HIV-1 for Maternal Health and for Reducing Perinatal HIV-1 Transmission in the United States.” MMWR Recommendations and Reports. Vol. 47 (No. RR-2), January 30, 1998
2. ↑ Newman, MD. “Women and HIV: The New Face of the Epidemic.” UCSF AIDS Program at SFGH. Medical Grand Rounds, January 25, 2000. Published at http://HIVInSite.ucsf.edu/topics/women/ 2098.45ef.html “New Developments in HIV Care for Women.”

Resources

1. HIV Warmline (Consultations for Providers): (800) 933-3413

2. WORLD (Women Organized to Respond to Life Threatening Diseases): phone (510) 658-6930, fax (510) 601-9746

3. http://HIVInSite.ucsf.edu