module 4 hiv infection in women. garrett colmorgen, md, director maternal fetal medicine, christiana...
TRANSCRIPT
![Page 1: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/1.jpg)
Module 4Module 4
HIV Infection in WomenHIV Infection in Women
![Page 2: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/2.jpg)
HIV Infection in WomenHIV Infection in Women
• Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware
• Staff of the Pennsylvania/Mid-Atlantic AIDS Education & Training Center, Delaware Local Performance Site - P. Lincoln, N. Bennett, M.A. Bartkowski
• Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware
• Staff of the Pennsylvania/Mid-Atlantic AIDS Education & Training Center, Delaware Local Performance Site - P. Lincoln, N. Bennett, M.A. Bartkowski
![Page 3: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/3.jpg)
Demographics of HIV in WomenDemographics of HIV in Women
• Fastest growing group in the United States • 4th leading cause of death aged 25 to 44 in
the United States• Disproportionately affects African
Americans & Hispanics living on the eastern seaboard
CDC-2000
• Fastest growing group in the United States • 4th leading cause of death aged 25 to 44 in
the United States• Disproportionately affects African
Americans & Hispanics living on the eastern seaboard
CDC-2000
![Page 4: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/4.jpg)
Statistics of HIV in WomenStatistics of HIV in Women
• Cumulative Statistics as of December 2000 in the United States 74,997 African American 28, 151 White 25,643 Hispanic 1,133 Other
• Total 130, 104 CDC
2000
• Cumulative Statistics as of December 2000 in the United States 74,997 African American 28, 151 White 25,643 Hispanic 1,133 Other
• Total 130, 104 CDC
2000
![Page 5: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/5.jpg)
HIV Transmission Risk Behaviors for WomenHIV Transmission Risk Behaviors for Women
• Heterosexual - 62% African American - 63% White - 18% Hispanic - 18% Other - 1% primary risk behavior for all age groups of women
• IVDU - 35%• Other - 3%
CDC 2000
• Heterosexual - 62% African American - 63% White - 18% Hispanic - 18% Other - 1% primary risk behavior for all age groups of women
• IVDU - 35%• Other - 3%
CDC 2000
![Page 6: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/6.jpg)
Female CondomFemale Condom
• “Reality” - only brand currently marketed in the US
• Made of polyurethane, sheath closed at one end with flexible rings at both ends
Anderson, J. 2001
• “Reality” - only brand currently marketed in the US
• Made of polyurethane, sheath closed at one end with flexible rings at both ends
Anderson, J. 2001
![Page 7: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/7.jpg)
MicrobicidesMicrobicides
• Strategy enabling women to have control over safer sex/prevention of HIV
• Nonoxynol-9 increases risk of HIV infection
• Clinical trials of topical microbicides are being conducted
Anderson, J. 2001
• Strategy enabling women to have control over safer sex/prevention of HIV
• Nonoxynol-9 increases risk of HIV infection
• Clinical trials of topical microbicides are being conducted
Anderson, J. 2001
![Page 8: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/8.jpg)
Gender Bias TransmissionGender Bias Transmission
• More efficient from man to woman than woman to man
• Related to number of infectious particles in body fluid
• Related to volume of fluids exchanged• Related to surface area coming in contact with
infected body fluid
HRSA:BPHC & AETC
• More efficient from man to woman than woman to man
• Related to number of infectious particles in body fluid
• Related to volume of fluids exchanged• Related to surface area coming in contact with
infected body fluid
HRSA:BPHC & AETC
![Page 9: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/9.jpg)
Risk Factors for Male to Female HIV Transmission
Risk Factors for Male to Female HIV Transmission
• Anal Intercourse
• Lack of male circumcision
• Genital ulcers (syphilis, herpes simplex, chancroid)
• Sexually Transmitted Diseases
• Multiple sexual partners
• Anal Intercourse
• Lack of male circumcision
• Genital ulcers (syphilis, herpes simplex, chancroid)
• Sexually Transmitted Diseases
• Multiple sexual partners
![Page 10: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/10.jpg)
Special ConsiderationSpecial Consideration
• Early Adolescent immaturity of the female genital track
increases risk of transmission
• Women over 50 years of age atrophic vaginitis caused by decreased
lubrication older females are generally not perceived to
be at risk
• Early Adolescent immaturity of the female genital track
increases risk of transmission
• Women over 50 years of age atrophic vaginitis caused by decreased
lubrication older females are generally not perceived to
be at risk
![Page 11: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/11.jpg)
Natural History of HIV Disease in Women
Natural History of HIV Disease in Women
• Same as in men except for GYN symptoms and disease conditions
• 1993 CDC added invasive cervical cancer as an AIDS defining condition
• Women are often diagnosed late• Women may have barriers to care
HRSA:BPHC & AETC
• Same as in men except for GYN symptoms and disease conditions
• 1993 CDC added invasive cervical cancer as an AIDS defining condition
• Women are often diagnosed late• Women may have barriers to care
HRSA:BPHC & AETC
![Page 12: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/12.jpg)
Challenges in Caring for Women with HIV
Challenges in Caring for Women with HIV
• Statistically economically poorer than men
• More likely to be single parents lack of child care lack of support
• More likely to be uninsured HRSA:BPHC & AETC
• Statistically economically poorer than men
• More likely to be single parents lack of child care lack of support
• More likely to be uninsured HRSA:BPHC & AETC
![Page 13: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/13.jpg)
Signs and Symptoms of HIV in Women
Signs and Symptoms of HIV in Women
• Acute Seroconversion - (No distinct gender differences however many of these s&s often go under addressed) fever swollen glands
Bartlett, J. 1999
• Acute Seroconversion - (No distinct gender differences however many of these s&s often go under addressed) fever swollen glands
Bartlett, J. 1999
![Page 14: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/14.jpg)
Signs and Symptoms of HIV in Women cont’
Signs and Symptoms of HIV in Women cont’
Rash - macular or maculopapular, usually nonpururitic. Truncal / facial distribution can involve arms and legs. Often appears several days past onset of fever.
Fatigue Mono-spot test is negative
Bartlett, J. 1999
Rash - macular or maculopapular, usually nonpururitic. Truncal / facial distribution can involve arms and legs. Often appears several days past onset of fever.
Fatigue Mono-spot test is negative
Bartlett, J. 1999
![Page 15: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/15.jpg)
HIV-Related Gynecological Conditions
HIV-Related Gynecological Conditions
• Vaginal candidiasis
• Human Papilloma Virus
• Genital Ulcers
• Pelvic Inflammatory Disease
• Cervical Dysplasia/Neoplasia
• Menstrual Disturbances HRSA:BPHC & AETC
• Vaginal candidiasis
• Human Papilloma Virus
• Genital Ulcers
• Pelvic Inflammatory Disease
• Cervical Dysplasia/Neoplasia
• Menstrual Disturbances HRSA:BPHC & AETC
![Page 16: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/16.jpg)
Diagnostic StudiesDiagnostic Studies
• Pap smear two studies the first year of diagnosis annually if normal recommended every 6 months if HIV is
symptomatic
• Colposcopy
USPHS/IDSA 2001
• Pap smear two studies the first year of diagnosis annually if normal recommended every 6 months if HIV is
symptomatic
• Colposcopy
USPHS/IDSA 2001
![Page 17: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/17.jpg)
Prenatal & Family Planning HIV Screening
Prenatal & Family Planning HIV Screening
• DHHS guidelines suggest universal HIV testing with patient notification as a routine component of prenatal care
• Pre and post test counseling & informed consent - laws vary by state
USPHS/IDSA 2001
• DHHS guidelines suggest universal HIV testing with patient notification as a routine component of prenatal care
• Pre and post test counseling & informed consent - laws vary by state
USPHS/IDSA 2001
![Page 18: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/18.jpg)
PregnancyPregnancy
• Does not appear to accelerate HIV infection
• Does not appear to accelerate HIV infection
![Page 19: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/19.jpg)
Perinatal HIV Transmission May Occur
Perinatal HIV Transmission May Occur
• Antepartum during pregnancy
• Intrapartum during labor during delivery
• Postpartum-through breast feeding HRSA:BPHC & AETC
• Antepartum during pregnancy
• Intrapartum during labor during delivery
• Postpartum-through breast feeding HRSA:BPHC & AETC
![Page 20: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/20.jpg)
Reducing Perinatal TransmissionReducing Perinatal Transmission
• ACTG 076 women given AZT after first trimester AZT administered intravenously during labor newborn receives AZT for 6 weeks transmission reduced by 67.5%
• Combination therapy has reduced the rate even further
HRSA:BPHC & AETC
• ACTG 076 women given AZT after first trimester AZT administered intravenously during labor newborn receives AZT for 6 weeks transmission reduced by 67.5%
• Combination therapy has reduced the rate even further
HRSA:BPHC & AETC
![Page 21: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/21.jpg)
Antepartum/Intrapartum Management Considerations
Antepartum/Intrapartum Management Considerations
• Avoid amniocentesis
• Avoid premature rupture of membranes
• Avoid fetal scalp monitoring• Delay episiotomy
HRSA:BPHC & AETC
• Avoid amniocentesis
• Avoid premature rupture of membranes
• Avoid fetal scalp monitoring• Delay episiotomy
HRSA:BPHC & AETC
![Page 22: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/22.jpg)
HIV Medications to avoid during Pregnancy
HIV Medications to avoid during Pregnancy
• Efavirenz - associated with anencephaly, anopthalmia Neural tube defects in primates
• Indinavir - Potential for nephrolithiasis and neonatal hyperbilirubinemia
DeLorenzo, L. 2001
• Efavirenz - associated with anencephaly, anopthalmia Neural tube defects in primates
• Indinavir - Potential for nephrolithiasis and neonatal hyperbilirubinemia
DeLorenzo, L. 2001
![Page 23: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/23.jpg)
HIV Medications to avoid during Pregnancy, cont’
HIV Medications to avoid during Pregnancy, cont’
• Didanosine/Stavudine - combination associated with fatal lactic acidosis in pregnancy
• Stavudine/Retrovir -combination is antagonistic, decreasing efficacy of therapy
DeLorenzo, L. 2001
• Didanosine/Stavudine - combination associated with fatal lactic acidosis in pregnancy
• Stavudine/Retrovir -combination is antagonistic, decreasing efficacy of therapy
DeLorenzo, L. 2001
![Page 24: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/24.jpg)
Antiretroviral Pregnancy RegistryAntiretroviral Pregnancy Registry
• Collaborative effort between the CDC, NIH and pharmaceutical companies to monitor for birth defects in infants exposed to antiretroviral agents
• antiretroviral exposure during pregnancy should be reported to the registry at 1-800-258-4263
Anderson, J. 2001
• Collaborative effort between the CDC, NIH and pharmaceutical companies to monitor for birth defects in infants exposed to antiretroviral agents
• antiretroviral exposure during pregnancy should be reported to the registry at 1-800-258-4263
Anderson, J. 2001
![Page 25: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/25.jpg)
Current Prevention Message-Is it Reality ?
Current Prevention Message-Is it Reality ?
• Abstinence
• Monogamy
• Reduce number of partners
• Ask partner about history of infection
• Enforce use of condoms
Colmorgen, G. 1999
• Abstinence
• Monogamy
• Reduce number of partners
• Ask partner about history of infection
• Enforce use of condoms
Colmorgen, G. 1999
![Page 26: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/26.jpg)
Prepared by Christopher W. James, Pharm.D.Clinical Pharmacist, HIV Community Program5/6/02
FDA Pregnancy Categories for Antiretroviral Agents and Associated Medications
Category A
Controlled StudiesShow No Risk
Category B
No Evidence of Risk inHumans
Category C
Risk Cannot Be Ruled Out
Category D
Positive Evidenceof Risk
Category X
Contraindicated InPregnancy
Amphotericin BAzithromycinClindamycin
CyproheptadineDidanosine
Growth HormoneMetronidazole
NelfinavirNystatinRifabutinRitonavir
SaquinavirTenofovir
AbacavirAcyclovir
AlbendazoleAmprenavir*†AtovaquoneCidofovir
CiprofloxacinClarithromycinClotrimazole
DapsoneDelaviridineDronabinolEfavirenz*
ErythropoietinEthambutolFluconazoleFlucytosineFomivirsenFoscarnet
GanciclovirIndinavir
InterferonsIsoniazid
ItraconazoleLamivudine
Lopinavir/RitonavirNevirapine
PentamidinePrimaquine
PyrazinamidePyrimethamine
StavudineSulfadiazine
TrimethoprimTrimethoprim/
SulfamethoxazoleZalcitabineZidovudine
HydroxyureaMegestrol Acetate
OxandroloneRibavirin
TestosteroneThalidomide
* Contraindicated in pregnancy† Oral solution only; contains significant amount of propylene glycol
![Page 27: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/27.jpg)
ReferencesReferences
• Anderson, J. (Ed.) (2001). A guide to the clinical care of women with HIV. Rockville, MD: HIV/AIDS Bureau, Health Resources and Services Administration. [Available on-line: http://www.hab.hrsa.gov/publications.html].
• Bartlett, J. & Gallant, J. (2001). 2001-2002 Medical Management of HIV Infection. [Available on-line: http;//hopkins-aids.edu
• Anderson, J. (Ed.) (2001). A guide to the clinical care of women with HIV. Rockville, MD: HIV/AIDS Bureau, Health Resources and Services Administration. [Available on-line: http://www.hab.hrsa.gov/publications.html].
• Bartlett, J. & Gallant, J. (2001). 2001-2002 Medical Management of HIV Infection. [Available on-line: http;//hopkins-aids.edu
![Page 28: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/28.jpg)
References, cont’References, cont’
• Center for Disease Control and Prevention. (2002,February). Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. [Available on-line: http://www.hivatis.org.]
• Center for Disease Control and Prevention. (2002,February). Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. [Available on-line: http://www.hivatis.org.]
![Page 29: Module 4 HIV Infection in Women. Garrett Colmorgen, MD, Director Maternal Fetal Medicine, Christiana Care Health Services, Wilmington, Delaware Staff](https://reader035.vdocuments.mx/reader035/viewer/2022062715/56649da95503460f94a96077/html5/thumbnails/29.jpg)
References, cont’References, cont’
• DeLorenzo, L. (2001). Clinical Nursing Series. Nursing Care of the HIV-Infected Patient. Fourth Edition. Western Schools Press.
• DeLorenzo, L. (2001). Clinical Nursing Series. Nursing Care of the HIV-Infected Patient. Fourth Edition. Western Schools Press.