HIV and Reproduction

Dr Felicia Molokoane2012

Introduction• 40 million people are living with

HIV/AIDS• SA is one of the fastest growing HIV

epidemic• Majority of HIV infected people are

women• Now the number has stabilised due

to ART's

Mode of Transmission• Sexual• Parenteral• Perinatal

Outline• HIV and gynaecological neoplasia• HIV and gynaecological infections• HIV and infections• HIV and infertility• HIV and pregnancy

HIV and gynaecological neoplasia

• HIV infected women are at increased risk for developing low and high grade squamous intraepithelial lesions (LSIL and HSIL), atypia (ASCUS) and carcinoma

• The high risk types HPV 16 and 18 are highly associated with abnormal cervical smears

Human papilloma virus• HIV infected women have a higher

prevalence of infection with HPV

• Likely to develop persistent infection with multiple HPV's

• Higher incidence and prevalence of SIL and likely progression to invasive cancer

Human papilloma virus• Effect of ARTs on HPV infection and CIN

is not yet established

• ARTs has the potential to prevent progression of HPV infection

• Screening:– Cervical cytology– HPV DNA screening

Human papilloma virus• Treatment:– Cryotherapy– Large loop excision of the

transformation zone– Cone biopsy– Cure rate >85%

Cervical neoplasia• Women with HIV are more likely to

present with multifocal disease

• Progress more rapidly to cervical cancer

• Neoplasia is more likely to recur after treatment

• Other HPV types are found, 52 and 58

Vulvar and perianal pathology

• HIV infected women are at increased risk of acquiring genital warts and vulvar intraepithelial neoplasia

• ARTs decreases the risk of these conditions

HIV and gynaecological infections

• Vulvovaginal candidiasis

• Bacterial vaginosis

• Genital ulcers

• PID

Vulvovaginal candidiasis• Risk factors:– HIV, pregnancy, high oestrogen oral contraceptive,

uncontrolled diabetes, broad spectrum antibiotics and long term corticosteroids use

• Promotes HIV acquisition by causing local inflammation on the vaginal mucosa, this disrupting the epithelium

• Treatment is usually local or systemic for recurrent or complicated cases

Bacterial vaginosis• Leading cause of vaginal discharge

• Increase susceptibility to HIV by 1.4

• Treatment: Metronidazole – (2x 1g tablets rectal STAT ) – (2g oral STAT)

Genital ulcers• Herpes Simplex Virus:– Prevalence is increasing in parallel to that of HIV– Frequent reactivation rate– Treatment with acyclovir for 5 days

• Syphilis:– Associated with 2.5 increase in acquiring HIV– All individuals with syphilis should be tested for

HIV– Treatment is benzathine penicillin

Genital ulcers• Chancroid:– Associated with 2.3 fold increased risk of

acquiring HIV–Multiple ulcers, persist for longer

duration– Treatment: Tetracycline for 14 days

PID• Common causative agents are

gonorrhoea and chlamydia

• Present with higher temperatures

• Tend to have adnexal masses or tubo ovarian complexes

• Require surgical intervention

PID• CDC recommends:– Standard antibiotic regimen–May be febrile for 48 hours– Change the regime after 2 to 4 days

HIV and contraception• The choice of contraception for HIV

infected women is often complicated:– Specific contraceptives and their

efficacy in preventing pregnancy– Prevention of transmission of HIV and

other STDs– Drug interactions between certain

antiretroviral agents and hormonal contraceptives

Hormonal contraceptives• COCs have decreased contraceptives efficacy

when taken with some ART regimens:– Liver enzyme inducing drugs, e.g. Protease

inhibitors and NNRTI– Choice COCs with oestrogen profile of >30μg– Combine OCs with barrier methods

• Transdermal and transvaginal delivery:– Hepatic metabolism is avoided– Use with barrier methods– At risk of VTE

Hormonal contraceptives• DMPA:– Has no known interaction with ARTs– Unaffected by the liver enzymes– Large numbers of HIV + use DMPA– Evidence that DMPA can affect viral burden– Lavreys et al 2004 notes that the use of DMPA

in early HIV-1 infection increases the viral set point and subsequently the viral load for HIV infected women

– The risk of low bone density, in long term users

Hormonal contraceptives• Intrauterine devices:– Levonogestrel intrauterine system and

copper based IUDs are highly effective, long term, convenient and safe methods of contraception for many HIV stable women

– Less likely to become pregnant– If IUD removed, fertility returns quickly

HIV and infertility• Treatment of infertility in HIV infected

couples has always been controversial

• The need for infertility services may be high among HIV infected women:– 20% have menstrual abnormalities– Tubal diseases

• Infertility treatment on HIV serodiscordant couple should be individualised

HIV and infertility• Induction of ovulation and avoid

intercourse:– IUI– IVF or ICSI

• Sperm washing

HIV and pregnancy• Many women with HIV are diagnosed

during pregnancy

• 1 in 3 pregnant women

• Check the ART regimen, because some of the drugs are teratogenic

HIV and pregnancy• Miscarriages• Stillbirth• Growth restriction• Low birth weight• Risk of perinatal transmission

Conclusion• Most women acquire HIV infection via

heterosexual contact• More likely to have co-incident

gynaecological conditions• The incidence and severity of these

conditions are related to the immune deficiency

• Regular gynaecological evaluation should be done in all HIV infected women