1. HIV and Reproduction Dr Felicia Molokoane 2012

2. 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

3. Mode of Transmission • Sexual • Parenteral • Perinatal

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

5. 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

6. 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

7. 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

8. Human papilloma virus • Treatment: • Cryotherapy • Large loop excision of the transformation zone • Cone biopsy • Cure rate >85%

9. 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

10. 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

11. HIV and gynaecological infections • Vulvovaginal candidiasis • Bacterial vaginosis • Genital ulcers • PID

12. 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

13. Bacterial vaginosis • Leading cause of vaginal discharge • Increase susceptibility to HIV by 1.4 • Treatment: Metronidazole • (2x 1g tablets rectal STAT ) • (2g oral STAT)

14. 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

15. Genital ulcers • Chancroid: • Associated with 2.3 fold increased risk of acquiring HIV • Multiple ulcers, persist for longer duration • Treatment: Tetracycline for 14 days

16. PID • Common causative agents are gonorrhoea and chlamydia • Present with higher temperatures • Tend to have adnexal masses or tubo ovarian complexes • Require surgical intervention

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. HIV and infertility • Induction of ovulation and avoid intercourse: • IUI • IVF or ICSI • Sperm washing

24. 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

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

26. 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