HIV Screening and Women’s Health

1. Originally developed by: Health Care Education & Training, Inc. HIV Screening and Women’s Health Section 4: Gynecological Manifestations of HIV Infection

2. 2007 Contributors from AETC Women’s Health and Wellness Workgroup: • Joyce Alley, RN; Health Care Education and Training, Inc. • Laura Armas, MD; Texas/Oklahoma AETC • Andrea Norberg, MS, RN; AETC National Resource Center • Tonia Poteat, MPH, MMSc, PA-C; Southeast ATEC (SEATEC) • Barbara Schechtman, MPH; Midwest ATEC (MATEC) • Karen Sherman, MA; Health Care Education and Training, Inc. • Jamie Steiger, MPH; AETC National Resource Center The original curriculum was developed in 2002 by MATEC and Health Care Education & Training, Inc. HIV Screening and Women’s Health

3. Objective for Section 4: • Discuss gynecological problems that indicate a need for HIV screening, including: • Vaginal discharge/irritation • Abnormal uterine bleeding/amenorrhea • Abnormal Pap smear • Genital warts • Genital ulcers • Pelvic/abdominal pain and Pelvic Inflammatory Disease (PID) HIV Screening and Women’s Health

4. 41% 59% Co-Occurrence of HIV and Gynecologic Disorders Women with gynecologic disorder(s) at enrollment • Anogenital warts • Syphilis • Amenorrhea • Symptomatic candidiasis • Oncogenic HPV • Abnormal Pap smear (Minkoff et al., 1999) HIV Screening and Women’s Health

5. CDC HIV/AIDS Classification System: GYN Manifestations HIV Screening and Women’s Health

6. Vaginal Discharge/Irritation • Women with frequent and/or persistent vaginal discharge should be offered an HIV test • STIs indicate HIV risk behavior and an increased risk for HIV acquisition • Bacterial Vaginosis can increase a woman’s risk of acquiring HIV • Yeast infections are common among women with HIV; therefore, frequent and persistent yeast infections are a cue for HIV testing HIV Screening and Women’s Health

7. Recurrent Yeast Vaginitis as a Common Presenting Symptom of HIV • Prevalence of candiasis among HIV positive women is 3-15% • HIV positive women with CD4 cell counts <200 have significantly increased odds of vaginal or oral colonization of Candida • Recurrent yeast vaginitis is the most common presenting symptom of HIV infection Credit: Jean R. Anderson, MD HIV Screening and Women’s Health

8. Abnormal Uterine Bleeding • Abnormal uterine bleeding/menstrual disorders are very common among HIV positive women • Bleeding may not be due to HIV disease, but possibly to related factors such as: • Weight loss • Chronic disease • Substance abuse • Use of progesterone (for appetite stimulation or contraception) HIV Screening and Women’s Health

9. Abnormal Pap Smear • 30-60% of Pap smears from HIV positive women have cytological abnormalities (Larkin et al., 1999) • 15-40% of these Pap smears exhibit dysplasia (Larkin et al., 1999) • Women with HIV are more likely to have persistence of HPV and cervical dysplasia HIV Screening and Women’s Health

10. Abnormal Pap Smears in HIV Positive Women • Genital Tract Neoplasia HIV Screening and Women’s Health

11. Cervical Neoplasia • Cervical cancer is an AIDS defining illness • In a study of 2,015 HIV-infected women and 577 seronegative controls, 58% of HIV- infected women had HPV as compared with the seronegative controls of 26% • In HIV positive women, dysplasia is associated with more extensive cervical involvement and is more likely to involve other sites in the lower genital tract HIV Screening and Women’s Health

12. HPV as a Common Presenting Symptom of HIV Before Treatment After Treatment Credit: Cliggott Publishing Credit: Cliggott Publishing HIV Screening and Women’s Health

13. Genital Ulcers • Diseases which present with genital ulcers and may be associated with HIV disease include: herpes, syphilis, chancroid, cytomegalovirus, lymphogranuloma venereum, granuloma inguinale, and tuberculosis • Women with HIV often experience more severe manifestations of these diseases due to immunosuppression • Genital ulcers serve as a portal of entry for HIV; thus women affected by such ulcers are at a greater risk of infection HIV Screening and Women’s Health

14. Pelvic/Abdominal Pain • Pelvic inflammatory disease (PID) or pregnancy are common causes of pelvic pain • Many studies have shown an increased prevalence of HIV in hospitalized PID patients, indicating that providers should offer women with PID an HIV test • All pregnant women should be offered an HIV test, as part of routine prenatal care HIV Screening and Women’s Health

15. Resources • AIDS Education and Training Centerswww.aidsetc.org • Cervical Cancer Screening and the HIV-Infected Woman slide set • Human Papillomavirus and the HIV-Infected Woman slide set • Common Sexually Transmitted Diseases and the HIV-Infected Woman slide set • Title X Family Planning Regional Training Centershttp://opa.osophs.dhhs.gov/titlex/ofp-training-grantees-listing.html • Health Resources and Services Administration, HIV/AIDS Bureau http://hab.hrsa.gov/publications/womencare05/index.htm • A Guide to the Clinical Care of Women with HIV, 2005 edition, Ed. Jean R. Anderson HIV Screening and Women’s Health

16. References • Ahdieh, L., Klein, R.S., Burk, R., Cu-Uvin, S., Schuman, P., Duerr, A., Safaeian, M., Astemburski, J., Daniel, R., & Shah, K. (2001). Prevalence, incidence, and type-specific persistence of human papillomavirus in human immunodeficiency virus (HIV)-positive and HIV-negative women. Journal of Infectious Diseases, 184: 682–690. • Ahdieh, L., Munoz, A., Vlahov, D., Trimble, C., Timpson, L., & Shah, K. (2000). Cervical neoplasia and repeated positivity of human papillomavirus infection in human immunodeficiency virus-seropositive and -seronegative women. American Journal of Epidemiology, 151: 1148–1157. • American Society For Colposcopy and Cervical Pathology. Consensus Guidelines. Retrieved on August 6, 2007 from http://www.asccp.org/ • Anderson, J.R., ed. (2005). A Guide to the Clinical Care of Women with HIV. Health Resources and Services Administration HIV/AIDS Bureau. • Branca, M., Garbuglia, A.R., Benedetto, A., Cappiello, T., Leoncini, L., Migliore, G., Agarossi, A., & Syrjanen, K. (2003). Factors predicting the persistence of genital human papillomavirus infections and Pap smear abnormality in HIV-positive and HIV-negative women during prospective follow-up. International Journal of STDs & AIDS, 14: 417–425. • Centers for Disease Control and Prevention. 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults. MMWR, December 18, 1992, 41 (RR-17). • Centers for Disease Control and Prevention. (2004). Bacterial Vaginosis Fact Sheet. Retrieved on August 6, 2007 from http://www.cdc.gov/std/bv/STDFact-Bacterial-Vaginosis.htm • Centers for Disease Control and Prevention. Sexually Transmitted Diseases Guidelines 2006. Retrieved on August 6, 2007 from http://www.cdc.gov/std/treatment/ HIV Screening and Women’s Health

17. References (continued) • Evander, M., Edlund, K., Gustafsson, A., Jonsson, M., Karlsson, R., Rylander, E., & Wadell, G. (1995) Human papillomavirus infection is transient in young women: a population-based cohort study. Journal of Infectious Diseases, 171: 1026–1030. • Feingold A.R., Vermund, S.H., Burk, R.D., Kelley, K.F., Schrager, L.K., Schreiber, K., Munk, G., Friedland, G.H., & Klein, R.S. (1990). Cervical cytologic abnormalities and papillomavirus in women infected with human immunodeficiency virus. Journal of Acquired Immune Deficiency Syndromes. 3(9): 896-903. • Garcia, P.M. & Sha, B.E. (2000) Women and HIV: Continuing the Challenge. Retrieved on August 6, 2007 from http://www.medscape.com/viewprogram/621 • Grulich, A.E., Li, Y., Correll, P., McDonald, A., & Kaldor, J.M. (2000) National linkage of HIV, AIDS and cancer incidence data. 4th International AIDS Malignancy Conference. Journal of Acquired Immune Deficiency Syndromes, 23: A15 (abstract 1). • Heard, I., Tassie, J.M., Schmitz, V., Mandelbrot, L., Kazatchkine, M.D., & Orth, G. (2000). Increased risk of cervical disease among human immuodeficiency virus-infected women with severe immunosuppression and high human papillomavirus load. Obstetrics & Gynecology, 96: 403–409. • Hillemanns, P., Ellerbrock, T.V., McPhillips, S., Dole, P., Alperstein, S., Johnson, D., Sun, X.W., Chiasson, M.A., & Wright, T.C. (1996). Prevalence of anal cytologic abnormalities and anal human papillomavirus infections in HIV-seropositive women. AIDS, 10: 1641–1647. • Ho, G.H., Bierman, R., Beardsley, L., Chang, C.J., & Burk, R.D. (1998). Natural history of cervicovaginal papillomavirus infection in young women. New England Journal of Medicine, 338: 423–428. • Holly, E.A., Ralston, M.L., Darragh, T.M., Greenblatt, R.M., Jay, N., & Palefsky, J.M. (2001). Prevalence and risk factors for anal squamous intraepithelial lesions in women. Journal of the National Cancer Institute, 93: 843–849. HIV Screening and Women’s Health

18. References (continued) • Jamieson, D.J., Duerr, A., Burk, R., Klein, R.S., Cu-Uvins, S., Paramsothy, P. Shah, K., & Schuman, P. (2002). HIV Epidemiology Research Study (HERS). Characterization of genital human papillomavirus infection in women who have or who are at risk of having HIV infection. American Journal of Obstetrics & Gynecology, 186: 21–27. • Kiviat, N.B., Critchlow, C.W., Holmes, K.K., Kuypers, J., Sayer, J., & Dunphy, C. (1993). Association of anal dysplasia and human papillomavirus with immunosuppression and HIV infection among homosexual men. AIDS, 7: 43–49. • Korn, A.P. & Landers, D.V. (1995). Gynecologic disease in women infected with human immunodeficiency virus type 1. Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology. 9 (4): 361-70. • Lacey, H.B., Wilson, G.E., & Tilston, P. (1999). A study of anal intraepithelial neoplasia in HIV-positive homosexual men. Sexually Transmitted Infections, 75: 172–177. • Larkin, J.A., Minerva, K., Hold, D., & Nadler, J. (1999). Women and HIV: When to Test? AIDS Reader, 9 (3): 175-183. • Luque, A.E., Demeter, L.M., & Reichman, R.C. (1999). Association of human papillomavirus infection and disease with magnitude of human immunodeficiency virus type 1 (HIV-1) RNA plasma level among women with HIV-1 infection. Journal of Infectious Diseases, 179: 1405–1409. • Maiman, M., Fruchter, R.G., Serur, E., Remy, J.C., Feuer, G., & Boyce, J. (1990). Human immunodeficiency virus infection and cervical neoplasia. Gynecological Oncology, 38: 377–382. • Massoud et al. (2000). Conf Retroviruses and Opportunistic Infections (abstract 675). • Minkoff H.L., Eisenberger-Matityahu, D., Feldman, J., Burk, R., & Clarke, L. (1999). Prevalence and incidence of gynecologic disorders among women infected with human immunodeficiency virus. American Journal of Obstetrics & Gynecology, 180: 824–836. HIV Screening and Women’s Health

19. References (continued) • Minkoff, H., Feldman, J., DeHovitz, J., Landesman, S., & Burk, R. (1998). A longitudinal study of human papillomavirus carriage in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women. American Journal of Obstetrics & Gynecology, 178: 982–986. • Palefsky, J.M., Holly, E.A., Hogeboom, C.J., Berry, J.M., Jay, N., & Darragh, T.M. (1997) Anal cytology as a screening tool for anal squamous intraepithelial lesions. Journal of Acquired Immune Deficiency Syndromes ,14: 415–422. • Palefsky, J.M., Holly, E.A., Ralston, M.L., Da Costa, M., & Greenblatt, R.M. (2001a). Prevalence and risk factors for anal human papillomavirus infection in human immunodeficiency virus (HIV)-positive and high-risk HIV-negative women. Journal of Infectious Diseases, 183: 383–391. • Palefsky, J.M., Minkoff, H., Kalish, L.A., Levine, A., Sacks, H.S., Garcia, P., Young, M., Melnick, S., Miotti, P., & Burk, R. (1999). Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high risk HIV-negative women. Journal of theNational Cancer Institute, 91: 226–236. • Petry, K.U., Kochel, H., Bode, U., Schedel, I., Niesert, S., Glaubitz, M., Maschek, H., & Kuhnle, H. (1996). Human papillomavirus is associated with the frequent detection of warty and basaloid high-grade neoplasia of the vulva and cervical neoplasia among immunocompromised women. Gynecologic Oncology, 60: 30–34. • Schuman, P., Ohmit, S.E., Vazquez, J., Klein, R.S., Mayer, K., Rompalo, A., Jamieson, D., & Sobel, J.D. (2000). Longitudinal assessments of oral and vaginal candida colonization, species, and fluconazole susceptibility in HIV-seropositive women. The HER study. Conf Retroviruses Opportunistic Infect 2000 Jan 30-Feb 2; 7:202 (abstract no. 676) • Sun, X.W., Ellerbrock, T.V., Lungu, O., Chiasson, M.A., Bush, T.J., & Wright, T.C. (1995). Human papillomavirus infection in HIV-seropositive women. Obstetrics & Gynecology, 85: 680–686. HIV Screening and Women’s Health

20. References (continued) • Sun, X.W., Kuhn, L., Ellerbrock, T.V., Chiasson, M.A., Bush, T.J., & Wright, T.C. (1997). Human papillomavirus infection in women infected with the human immunodeficiency virus. New England Journal of Medicine, 337: 1343–1349. • The AIDS Reader. (2000). Genital Warts in HIV. Retrieved on January 2, 2008 from http://www.medscape.com/viewarticle/410246_5 • Uberti-Foppa, C., Origoni, M., Maillard, M., Ferrari, D., Cuiffreda, D., Mastrorilli, E., Lassarin, A., & Lillo, F. (1998). Evaluation of the detection of human papillomavirus genotypes in cervical specimens by hybrid capture as screening for precancerous lesions in HIV-positive women. Journal of Medical Virology, 56: 133–137. • Williams, A., Darragh, T.M., Vranizan, K., Ochia, C., Moss, A.R., & Palefsky, J.M. (1994). Anal and cervical human papillomavirus infection and risk of anal and cervical epithelial abnormalities in human immunodeficiency virus-infected women. Obstetrics & Gynecology, 83: 205–211. HIV Screening and Women’s Health