Transcript Women and HIV

Women and HIV
Lucille Sanzero Eller, PhD, RN
Associate Professor
Rutgers, The State University of New Jersey
College of Nursing
A Local Performance Site of the NY/NJ AETC
September 2009
Objectives (1)
1. Discuss the epidemiology of HIV in women.
2. Describe gender-specific symptoms in HIV+
women.
3. Discuss ARV treatment considerations for
HIV+ women.
Objectives (2)
4. Identify psychological factors in HIV+
women.
5. Discuss contraception and pregnancy in
HIV+ women.
6. Describe assessment and counseling
issues for women with HIV.
Epidemiology of HIV in Women (1)

Proportion of AIDS cases in women steadily
increased since HIV epidemic began
– 1985 - 8% women
– 2006 - 27% women

Women of color disproportionately infected
– Black and Hispanic women comprise
25% of U.S. female population
 82% of women with HIV in the U.S.

Epidemiology of HIV in Women (2)

HIV infection in women in 2004
– leading cause of death for black women aged 25
to 34 years
– 3rd leading cause of death for black women
aged 35–44 years
– 4th leading cause of death for black women
aged 45–54 years and for Hispanic women aged
35–44 years
(CDC, May 2006)
Race/ethnicity of Women 2005: New
AIDS Diagnoses and Percentage of U.S.
Population (CDC, 2007)
New AIDS Diagnosis
U.S. Female Population


Black 66%
 White 16%
 Latina 16%
 Other 1%
CDC, HIV/AIDS SurveillanceReport,
Vol. 17, Revised Edition; June
2007.
Black 12%
 White 69%
 Latina 13%
 Other
6%
HIV Transmission in Women

Most common routes of HIV infection for
women
 sex with an HIV-positive man
 sharing injection drug works with someone with
HIV

Male to female transmission is 1.9 times
more effective than female to male
transmission; women are about twice as
likely as a man to contract HIV infection
during unprotected vaginal intercourse
Viral load

Viral load in women
 After adjustment for differences in
measurement method, baseline CD4+ cell count,
age, and clinical symptoms, HIV-1 RNA levels
were 32% to 50% lower in women than in men at
CD4+ counts >200 cells/mm3
 Despite lower viral loads, HIV disease
progresses at the same rate in women as in men
(Rezza et al., 2000)
 Current clinical guidelines do not make a
distinction by gender for the initiation of
HAART
HIV-related Hormonal Changes (1)

HIV can affect the body's ability to
produce and maintain hormone levels

Changes in the balance of estrogen,
progesterone, or testosterone can lead
to multiple symptoms (Margolese, 2004)
HIV-related Hormonal Changes (2)

Symptoms of hormonal imbalance:
 Abnormal menstrual cycles, possibly
including early menopause
 Weight loss
 Headaches
 Mood swings
 Depression
HIV-related Hormonal Changes (3)

Symptoms of hormonal imbalance:
 Sleep disturbances
 Fatigue
 Decreased bone density
 Vaginal dryness
 Lack of sexual desire
 Difficulty getting pregnant
HIV and Menstrual Problems (1)



Menstrual cycle changes
Increase in premenstrual symptoms
Changes may be due to
 HIV itself
 ARVs
 other co-factors that may occur with HIV
disease such as drug use
HIV and Menstrual Problems (2)

Hypermenorrhea- predisposes women to
anemia, already a chronic problem in
women with HIV

Amenorrhea- promptly evaluate for
underlying causes



pregnancy
ovarian cyst
ovarian failure and premature menopause
HIV and Osteopenia

Bone density in HIV+ (n=263) and HIV(n=232) women 40 years and older (Arnsten et
al., 2006)
 Osteopenia prevalence regardless of ART use:


27% in HIV+ women
19% in HIV- women
 Higher risk of osteopenia if:



Black
Underweight
Used opiates
HIV and Menopause (1)

“Ms Study” examined natural history of
menopause in HIV-infected and drug using
women (Schoenbaum, 2005)
 571 women, 52.9% HIV positive
 median age 43 years
 53% with history of illicit drug use
 89% women of color
HIV and Menopause (2)

Onset of menopause significantly differed:
 46 years [Interquartile Range (IQR) 39-49
years] for HIV+ women
 47 years [IQR 39-48 years] for HIV- women

Those with CD4+ counts <200 cells/mm3
had earliest onset (median age 42.5 years)
HIV and Menopause (3)

No association between receipt of HAART
and onset of menopause

Earlier onset of menopause combined with
HIV disease contributes to risk of
dyslipidemia and osteopenia
AIDS Complications in Women (1)

AIDS complications unique to women:
 recurrent vaginal candidiasis
 severe pelvic inflammatory disease
 cervical dysplasia
 cervical cancer
AIDS Complications in Women (2)

HIV+ women at higher risk of cervical
dysplasia, a precursor to cervical
cancer
 Risk of cervical cancer associated
with:


immune deficiency (declining CD4 counts and
higher HIV RNA levels)
human papillomavirus (HPV) which occurs in
more than 60% of women with HIV
(Abularach & Anderson, 2005)
HIV and Cervical Cancer (1)
Cervical Cancer
• Incidence is up to 9 times higher in HIV+
women
• Presents at more advanced stages
• Is less responsive to therapy
HIV and Cervical Cancer (2)

CDC Pap screening recommendations:
 Pap smear when first diagnosed, and
again 6 months later; then once yearly for
life
 Women with cervical abnormalities or CD4
counts <200 cells/mm3 should be
screened every 6 months for life
HIV and Oral Symptoms

Studies have shown a significant relationship
between high viral load and both oral candidiasis
and hairy leukoplakia (Greenspan et al, 2000; 2004; Patton et
al., 2000)

Recurrence and incidence of candidiasis are
reduced by HAART, and that recurrence is
reduced independent of CD4 count and HIV RNA
level
 HAART does not reduce the incidence of hairy
leukoplakia or oral warts in women (Greenspan et al.,
2004
HIV and Women: Studies (1)

The Women's Interagency HIV Study (WIHS)
 established in 1993
 investigated the impact of HIV infection on
women
 recruited 2066 HIV-positive and 575 HIV-negative
women from six sites in the U.S.

The Women and Infants Transmission
Studies (WITS)
 multi-site observational study established in
1989
 enrolled 2336 HIV-infected pregnant women
and 1887 infants born to them
HIV and Women: Studies (2)

10 primary care sites in the HIV
Research Network (HIVRN) (N=19,500)
(Gebo et al., 2005)
 HIV+ women less likely than HIV+ men to
receive prescriptions for the most
effective treatments for HIV infection
HIV and Women: Studies (3)
 Those less likely to receive clinically
indicated ART:

<40 y.o.; women; African-Americans; IDUs;
the uninsured or those with private insurance
 Those more likely to receive clinically
indicated ART:
older patients; men; Whites; Hispanics; those
with risk factors other than IDU; those with
Medicare coverage

HIV and Women: Treatment (1)
Recommendations for treatment of women of
reproductive age:
 Indications for initiation of therapy and goals of
treatment are same as for other adults and
adolescents
 Avoid Efavirenz for the woman who wants to
become pregnant or who does not use effective
and consistent contraception
Panel on Clinical Practices for Treatment of HIV Infection, 2008
HIV and Women: Treatment (2)
Recommendations for treatment of women of
reproductive age:

For the woman who is pregnant, an additional goal
of therapy is prevention of mother-to-child
transmission, with a goal of viral suppression to
<1,000 copies/mL

Selection of an ARV combination should consider
known safety, efficacy, and pharmacokinetic
data of each agent during pregnancy
(Panel on Clinical Practices for Treatment of HIV Infection, 2008)
Lipodystrophy Syndrome (1)

Metabolic and clinical features include:
 insulin resistance
 impaired glucose tolerance
 type 2 diabetes
 hypertriglyceridemia
 hypercholesterolemia
 increased free fatty acids (FFA)
 decreased high density lipoprotein (HDL)
 fat redistribution
Lipodystrophy Syndrome (2)
Factors that increase risk of lipodystrophy
syndrome include:
 increasing age
 current use and total duration of
antiretroviral therapy, including NRTIs and
PIs, but not NNRTIs
Carr, A. (2003). HIV lipodystrophy: risk factors, pathogenesis, diagnosis and
management. AIDS, 17 (1), S141-S148.
Lipodystrophy Syndrome (3)
•
Also associated with lipodystrophy are:
• Gender
• AIDS diagnosis
• greater CD4 lymphocyte and HIV RNA
•
•
•
•
responses to antiretroviral treatment
low body weight pre-therapy
elevated C-peptide and triglyceride levels after
about 1 year of therapy
use of the dual PI combination ritonavir–
saquinavir
use of thymidine analogues
Carr, A. (2003). HIV lipodystrophy: risk factors, pathogenesis, diagnosis and
management. AIDS, 17 (1), S141-S148.
Lipodystrophy Syndrome (4)
In a study of 2258 patients, women were twice
as likely as men to have lipodystrophy
Morphologic Alteration
Women
Fat loss only
9.3%
Fat accumulation only
10.1%
Both fat loss & accumulation 22.4%
Galli M, Veglia F, Angarano G, et al. Correlation between gender and morphologic
alterations in treated HIV patients. Program and abstracts of The 1st IAS Conference
on HIV Pathogenesis and Treatment; July 8-11, 2001; Buenos Aires, Argentina.
Abstract 505
Men
12.2%
7.7%
9.7%
Lipodystrophy Syndrome (5)
Morphologic changes of lipodystrophy
syndrome vary by gender:
Women tend to experience fat accumulation
in the abdomen and breasts
Men tend to experience fat depletion from the
face and extremities
Contraception (1)

WIHS study- effects of hormonal
contraceptives on HIV RNA and CD4 counts
(Cejtin et al., 2003)
 1721 women 50 y.o. or less, not menopausal
 controlled for CD4 count, tobacco use, age,
race, ART use, and a history of AIDS-defining
illnesses

No effect on viral load; small increase in
CD4 count, not clinically significant
Contraception (2)

WIHS study- effects of hormonal
contraceptives on effectiveness of HAART
(Chu et al., 2005)
 77 hormonal contraceptive users matched with
non-users on age, race, and pre-HAART CD4
count and viral load
 Followed from point of HAART initiation

No effect on CD4+ cell count and viral load
responses to HAART
Contraception (3)

Hormonal contraceptives can interact with
ARVs and cause any of the following:
 decreased contraceptive effectiveness
 increased concentrations of the ARV
 decreased concentrations of the ARV
e.g. Fos-Amprenavir should not be coadministered with hormonal contraceptives


Amprenavir increases blood levels of both estrogen
and progestin
oral contraceptives decrease Amprenavir levels
Contraception (4)

Copper IUDs
 are associated with increased menstrual flow
and duration
 May contributing to HIV transmission risk
 May contribute to anemia in HIV+ women
Stigma

Stigma of HIV disease has several negative
consequences
 secrecy and unwillingness to disclose





serostatus
fear of being identified as HIV positive
isolation
reduced access to care
difficulties with medication adherence
unwillingness to seek social support
(Carr & Gramling, 2004)
Social Support (1)

Social support includes the provision of
 Emotional support
 esteem
 affiliation
 Instrumental support
 financial
 housing
 Informational support
 advice
 information
Social Support (2)

Women with HIV receive less social support
than demographically similar women

Social support decreases as symptoms of
HIV increase (Hough et al., 2003; Klein et al., 2000)

Social support reduces psychological
distress and is a critical element in effective
coping with HIV (Hough et al., 2005)
Social Support: INSPIRE Study (1)

Baseline data of INSPIRE (Interventions for
Seropositive Injectors-Research and
Evaluation) study (Knowlton et al., 2006)
 Examined role of social support in
facilitating effective HAART use in 446
IDUs
 34% female, 69% Black, 26%
homeless, median age 43 years
Social Support: INSPIRE Study (2)
 Adjusted odds of undetectable viral load
(UVL) 3X higher in those with
 high social support
 stable housing
 CD4 > 200
 Adjusted odds of achieving UVL almost
60% higher (AOR = 1.57) in those
reporting better patient-provider
communication
Social Support: INSPIRE Study (3)

Interventions to facilitate effective
HAART use in IDUs should promote
 social support functioning
 patient-provider communication
 stable housing
 drug abuse treatment
(Knowlton et al., 2006)
Social Support

Study of social support in 147 poor, young
(M=36 y.o., SD=7) urban, African American
(87%) mothers with HIV (Hough et al. 2005)
 47% of primary support network, who provided
the most salient support, were children
 few friends, and almost no health care providers
were reported as sources of social support
Social Support: Assessment

Scale to assess social support in HIV+
women and abused women is the
Interpersonal Support Evaluation List (ISEL)
(Cohen et al., 1985)

Scale available at
http://www.psy.cmu.edu/~scohen/ISEL.html
Social Support: Study of
Unsupportive Social Interactions (1)

Presence of friends, family, significant
others is not necessarily supportive

Unsupportive social interactions may be
detrimental

Study of relationship-specific unsupportive
social interactions and depression in
146 HIV+ women (Scrimshaw, 2003)
Social Support: Study of
Unsupportive Social Interactions (2)







28% asymptomatic, 29% symptomatic, 43% with
AIDS
Mean age 35.6 years (SD D 5.6)
African American (33%), Puerto Rican (34%), White
(33%)
Incomes: 36% < $10,000; 48% $10,000 and
$19,999; 26% $20,000+
70% married or steady partner
73% mothers
55% IVDUs
Social Support: Study of
Unsupportive Social Interactions (3)

Unsupportive social interactions from family
 direct negative effect on depressive symptoms

Unsupportive interactions from a lover/
spouse and friends
 interactive effect on depression
 independently predicted high levels of
depressive symptoms
(Scrimshaw, 2003)
Social Support: Study of
Unsupportive Social Interactions (4)

Number of HIV-related physical symptoms
significantly associated with more
unsupportive social interactions from all
three sources:
 family
 lover/spouse
 friends
(Scrimshaw, 2003)
Assessment of Unsupportive Social
Interactions (1)

Assess unsupportive illness-related social
interactions during the past month
Responses range from never (1) to all the time (5)

Ask whether others:
1. Were trying to be overly optimistic or cheerful
2. Were avoiding you or was uncomfortable
being with you
3. Were unwilling to listen to you talk about
the illness
(Siegel et al., 1994; 1997)
Assessment of Unsupportive Social
Interactions (2)

Ask whether others:
4. Resented the demands the illness placed on
them
5. Said or did things that you found unhelpful or
disturbing
6. Made you more dependent on assistance than
you needed to be
(Siegel et al., 1994; 1997)
Assessment of Unsupportive Social
Interactions (3)

Questionnaire should be completed three times,
once each for
 lover/spouse
 family
 friends
 Calculate 3 separate summary scores (i.e., the
sum of the six items) to assess the frequency of
unsupportive social interactions in each type of
relationship
( Scrimshaw, 2003)
Depression (1)

In a study of 765 HIV+ women, 42% had
chronic depressive symptoms, and another
35% had intermittent depressive symptoms

(Ickovics, et al. , 2001

Depression is associated with:
 poorer virologic response
 increased likelihood of immunologic failure
 incident AIDS defining illness
 higher risk of all-cause, but not AIDS-related,
death
Depression (2)

Depression following HAART initiation was
associated with a greater likelihood of HAART
discontinuation (Anastos et al., 2005; Ickovics et al, 2001)

Psychotherapy, pharmacotherapy or combination
of both can be used to treat depression

Self-care strategies for management of depressive
symptoms used effectively by people with HIV
include prayer, meditation, talking to others,
using distraction, and exercise (Eller et al., 2005)
HIV and Pregnancy (1)

80% of HIV+ women are of childbearing age;
consider in ART regimen selection
See Public Health Service Task Force
Recommendations for Use of Antiretroviral Drugs
in Pregnant HIV-Infected Women for Maternal
Health and Interventions to Reduce Perinatal HIV
Transmission in the United States - April 29, 2009
Available at:
http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf
HIV and Pregnancy (2)

Care should include routine, regular
education and counseling about pregnancy/
contraception

Assess for factors associated with
unplanned pregnancies
 substance abuse by the woman or her partner
 mental illness
 domestic violence
HIV and Pregnancy (3)

About 1/3 of HIV+ women and men receiving
medical care in the U.S. desire children in
the future (Chen, 2001)

20% of serodiscordant couples would
practice unsafe sex in order to conceive
(Klein, 2003)
HIV and Pregnancy: Counseling (1)



Impact of HIV on pregnancy course/outcome
Impact of pregnancy on HIV progression
Other reproductive issues based on
maternal factors
 coexisting drug/alcohol use
 advanced maternal age
 hypertension, hyperglycemia, hepatic toxicity,
anemia
(Anderson, 2005; CDC, 2009)
HIV and Pregnancy: Counseling (2)

General preconception issues
 nutritional counseling (e.g. folic acid)
 importance of early and ongoing prenatal care

Long term health of mother and care for
children (guardianship issues)
(Anderson, 2005)
HIV and Pregnancy: Counseling (3)

Perinatal transmission
 Discuss and provide ARVs during pregnancy
regardless of woman’s HIV RNA level
 Breastfeeding not recommended in U.S. since
safe, affordable, feasible, culturally acceptable
alternatives are available

Use of antiretrovirals and other medications
in pregnancy

Safe conception if partner HIV-negative
(Anderson, 2005)
HIV and Pregnancy: CDC HIV Screening
Recommendations (4)

Screen all adults ages 13–64 in health care
settings; repeat screening annually if at high
risk

Include screening in all prenatal testing,
unless the patient declines; repeat
screening in 3rd trimester for women at highrisk for HIV

HIV testing of newborns if mother’s HIV
status unknown
HIV and Pregnancy: Studies (1)

Meta-analysis: 7 studies of effects of
pregnancy on HIV disease

No significant differences observed in:
 death
 HIV disease progression
 progression to an AIDS-defining illness
 fall in CD4 count to below 200/mm3
(French, 1998)
HIV and Pregnancy: Studies (2)

Effects of pregnancy on HIV disease
progression In women with repeat
pregnancy (n=329), compared to those with
only one pregnancy (n=953)

No significant differences observed in:
 viral load
 CD4
 clinical disease progression
(Minkoff et al., 2003)
Pregnancy and ARV Treatment: Study (1)
Meta-analysis of 14 clinical studies that
included European and American studies

ARV use during pregnancy did not increase
risk of premature delivery when compared to
no therapy [OR 1.01 (95% CI 0.76-1.34)]

Use of protease inhibitor (PI)-containing
combinations resulted in an OR for premature
delivery of 1.24 (95% CI 0.76-2.02), compared
with combinations without PI
Kourtis AP, Schmid CH, Jamieson DJ, et al. (2007)
http://www.ncbi.nlm.nih.gov/pubmed/17314523
Pregnancy and ARV Treatment: Study (2)
Meta-analysis of 14 clinical studies that
included European and American studies:

Initation of combination regimens
before or early in pregnancy may
slightly increase risk of prematurity
compared with initiation in the second
trimester or later [OR 1.71 (95% CI 1.092.67)]
Kourtis AP, Schmid CH, Jamieson DJ, et al. (2007)
http://www.ncbi.nlm.nih.gov/pubmed/17314523
Pregnancy and ARV Treatment (1)

Goals in use of ARVs during pregnancy:
 treatment of maternal infection
 reduction in the risk of perinatal transmission

Offer standard combination ARV therapy to
pregnant women who meet same criteria
other adults and adolescents
 two NRTIs and a PI or a NNRTI (excluding
efavirenz) (Anderson, 2005)
Pregnancy and ARV Treatment (2)

Considerations for ARV treatment
decisions: (Anderson, 2005)
 Treatment for health of the woman
 Current information re effectiveness of ART in
reducing perinatal transmission
 Known or potential effects of ARV drug
exposure on the pregnant woman and/or
fetus/newborn
 importance of adherence
Pregnancy and ARV Treatment (3)

Considerations re prevention of mother-tochild transmission (PMTCT) and maternal
and fetal safety influence
 timing of initiation of treatment
 selection of regimens
NOTE: Curriculum of the WHO and CDC
Prevention of Mother-to-Child Transmission of
HIV (PMTCT) Generic Training Package (July, 2008) is
available at
http://www.womenchildrenhiv.org/wchiv?page=pi-60-00
Pregnancy and ARV Treatment (4)

Drugs that cause GI upset
 may not be well tolerated in early pregnancy
when morning sickness is common
 may increase risk for non-adherence
 may have inadequate blood levels from
vomiting

All ARVs should be discontinued and
restarted when the nausea and vomiting is
gone or effectively treated
Pregnancy and Nevirapine (1)

Potential side effects of nevirapine in
pregnancy
 Women, esp. with CD4 counts >250/mm3, are at
increased risk for symptomatic, rashassociated, nevirapine-related hepatotoxicity
 Deaths from hepatic failure reported
 Early non-specific symptoms of hepatotoxicity
can be confused with symptoms common in
pregnancy (fatigue, malaise, anorexia, nausea)
Pregnancy and Nevirapine (2)

Potential side effects of nevirapine in
pregnancy (cont.)
 Women should be monitored for clinical
symptoms and hepatic transaminases (i.e., ALT
and AST), particularly during the first 18 weeks
of therapy, when toxicity is most likely
Pregnancy and Protease Inhibitors (1)

PIs are associated with development or
worsening of hyperglycemia or diabetes

Pregnancy also increases risk for glucose
intolerance

It is not known conclusively whether the use
of PIs in pregnancy will exacerbate risk for
development of gestational diabetes
Pregnancy and Protease Inhibitors (2)

For women receiving PIs in pregnancy
 monitor glucose levels
 ask regularly about symptoms of
hyperglycemia
Lactic acidosis and Hepatic steatosis (1)
 May have higher incidence in women
 Thought to be due to damage to
mitochondrial DNA (mitochondrial
toxicity) that is caused by long-term
nucleoside analogue use
 Reported to occur in infected persons
treated with NRTIs for >6 months
(Arenas-Pinto et al, 2003; CDC, 2008; McComsey & Lonergan, 2004)
Lactic acidosis and Hepatic steatosis (2)

Several maternal deaths due to lactic
acidosis/hepatic steatosis

All were in women receiving combination of
d4T/ddI as part of their ART at the time of
conception and for the duration of pregnancy

Non-fatal cases of lactic acidosis have also been
reported in pregnant women receiving this
combination
Lactic acidosis and Hepatic steatosis (3)

Early symptoms of mitochondrial
dysfunction are nonspecific and mimic
symptoms of pregnancy
 nausea and vomiting
 abdominal pain
 dyspnea
 weakness
Lactic acidosis and Hepatic steatosis (4)

Pregnant women receiving nucleoside
analogue drugs (NRTIs)
 should have liver enzymes and electrolytes
evaluated more frequently during the last
trimester of pregnancy
 should have new symptoms evaluated promptly
and thoroughly
Assessment and Counseling (1)

Women infected with HIV may have more
difficulty accessing health care due to:
 Fear of disclosure
 Lack of financial resources
 Lack of transportation
 Burden of caring for others, especially children
Assessment and Counseling (2)

Women often have difficulty negotiating
protective sex due to power differentials

Lack of power may cause women to:
 Have sex against their will
 Have sex without a condom, against their will
(CDC, May 2006)
Assessment and Counseling (3)

Lack of power may cause women to (cont.):
 Have sex with a man without knowing whether
he has high-risk behaviors (unprotected sex
with men, sex with many other partners,
injection drug use)
 Trade sex for drugs or money
 Be unable to talk to their partners about
abstinence, faithfulness, and condom use
(CDC, May 2006)
Assessment and Counseling (4)

Support system: At initial visit and at
intervals assess woman’s support system
 Who knows her HIV status
 Problems encountered with disclosure
 Family and/or friends to whom she turns for
ongoing support
 Barriers to disclosure to sexual or needlesharing partners
Assessment and Counseling (5)

Contraception:
 Discuss method of contraception
 If pregnant, discuss postpartum contraceptive
plans
 Educate and counsel about available options to
permit informed decision making

Condom use:
 Review sexual activity at each visit
 Reinforce condom use
Assessment and Counseling (6)

Drug use/treatment: At initial visit and at
intervals assess past/current substance
abuse (tobacco, alcohol, illicit drugs)
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Type of substance(s)
Amount of use
Route of administration
Prior drug or alcohol treatment
Counsel about specific risks associated with
substance abuse in pregnancy. Treatment
should be encouraged and facilitated for
active problems
Assessment and Counseling (7)
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Adherence: Assess and reinforce importance of
adherence to prescribed medications before they
are initiated and at each visit
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Clinical trials: Inform about the availability of and
offer participation in clinical trials for which
woman is eligible
Assessment and Counseling (8)
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Advance directives: Discuss advance directives
for care in the event of sudden deterioration in the
woman’s health
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Discuss guardianship plans for children in the
event of the mother’s incapacitation or death
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Facilitate legal assistance, if needed
Key Points (1)
1. The proportion of AIDS cases in women has
increased from 8% in 1985 to 27% in 2004.
2. Women of color are disproportionately
infected with HIV.
3. HIV’s effect on estrogen, progesterone and
testosterone leads to multiple symptoms.
Key Points (2)
4. HIV+ women are less likely than HIV+ men
to receive HAART.
5. Avoid efavirenz in pregnant women and
those at risk for pregnancy.
6. NRTI and PI-related lipodystrophy 2X more
common in HIV+ women vs. HIV+ men.
Key Points (3)
7. Contraception
 Hormonal contraceptives: no sig. effect on
CD4+ count, viral load, response to HAART
 IUD may increase menstrual flow, transmission
risk, anemia
8. Negative consequences of stigma include
 Fear of disclosure and identification as HIV+
 Isolation; reduced social support
 Reduced access
 Reduced adherence
Key Points (4)
9. Supportive and unsupportive social
interactions should be assessed.
10. HIV and pregnancy
 Assess risk for unplanned pregnancy
 Counsel re impact of HIV on pregnancy and
pregnancy on HIV disease
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ARVs (treat maternal infection; PMTCT)
potential side effects of nevirapine, PIs
lactic acidosis, hepatic steatosis
Key Points (5)
11. Assess and counsel regarding:
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Support system
Contraception
Condom use
Drug use and treatment
Adherence
Clinical trial availability
Advance directives
Guardianship
Legal assistance