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Primary care physicians will provide an increasing amount of care for women with HIV. Increased identification and early initiation of treatment of HIV infection with simpler and more potent ART has resulted in increased longevity and decreased mortality. Sex-specific issues such as pregnancy, breast and cervical cancer screening and prevention, and menopause have become more important components of the overall care of women with HIV. As such, women with HIV will rely less on specialized care and more on primary care physicians. Therefore, primary care providers need to become more knowledgeable of critical management considerations for this population and more comfortable determining when specialty consultation is needed. In general, the management of women with HIV in the primary care setting shares many similarities with the management of women without HIV but with some important differences. This section of the module will highlight key aspects of care provision for women with HIV that should be considered in the primary care setting.
Routine clinical care for women with HIV should include all of the following:
The DHHS adult ART guidelines recommend that all people with HIV initiate ART regardless of CD4+ cell count to prevent sexual transmission of HIV in addition to preventing disease progression in the individual. Factors that should be considered when selecting an initial ART regimen for women with HIV include childbearing potential and use of hormonal contraceptives, HIV serostatus of partners, risk for adverse events of ARV agents, comorbidities, and anticipated ARV adherence. Despite recommendations for ART initiation, considerable numbers of women with HIV with clinical indications for treatment in the United States are not receiving ART. In addition, there are several notable differences between the course of ART in women with HIV vs that in men with HIV, including higher rates of treatment-associated adverse events[110,117,128,130-133] and ART modification or discontinuation because of adverse events.
There are special considerations for reproductive health in women with HIV when compared with the general population. These include issues related to contraception, pregnancy, and menopause. Women with HIV infection often feel stigmatized by their diagnosis and, therefore, do not seek appropriate care, which can be detrimental to all facets of reproductive health. Primary care physicians can play an important role in addressing these issues by initiating discussions with women with HIV during routine primary care appointments.
When counseling women with HIV on the use of safe and effective contraception, primary care physicians can explain the importance of dual forms of contraception: barrier (condom) and hormonal (or sterilization). Dual mechanisms are necessary because ARV agents may alter the clinical effectiveness of many of the available contraceptive choices, and contraceptive agents may alter the efficacy of some ARV agents. In addition, barrier (condom) contraception is also important to reduce the risk of sexual transmission of HIV to intimate partners. Virologic responses to ART should be monitored closely when used in combination with nonbarrier contraceptives. Pharmacokinetic interaction should be considered when combined oral contraceptives and ARVs are used together and certain agents should not be used concurrently. Limited data exist regarding the use of implantable or intravaginal contraception in women with HIV. However, the CDC’s Medical Eligibility Criteria for Contraceptive Use lists all combined hormonal contraceptive methods (including the patch and vaginal ring) as Category 1 (no restriction for use) for women at high risk for HIV or with HIV or AIDS. Both the copper-containing intrauterine device (Tcu-380A IUD) and the levonorgestrel-releasing intrauterine contraceptive system are acceptable choices for women with HIV and do not appear to be associated with increased genital tract shedding of HIV.
The DHHS recommends the use of ART by all pregnant women with HIV to reduce the risk of mother-to-child transmission of HIV regardless of CD4+ cell count. In many cases, HIV infection may be initially diagnosed during pregnancy. The CDC, the American College of Obstetrics and Gynecology, and the DHHS all recommend routine prenatal HIV screening in the first trimester for all pregnant women, with repeat testing at other times during pregnancy in women who are at increased risk of acquiring HIV. In addition, women who present to labor and delivery with unknown HIV status or who are at risk for HIV acquisition should undergo rapid HIV testing. If the results of the rapid test are positive or unknown, intravenous zidovudine should be administered without waiting for confirmation of HIV status. Primary care physicians should involve both obstetrical providers and HIV specialists in the medical care of pregnant women with HIV throughout the entire gestational period especially regarding selection of appropriate ART, management of prenatal care and delivery, and treatment of infants exposed to HIV. Key management strategies for pregnant women with HIV include the following:
Based on the success of ART, the proportion of women with HIV who are 50 years of age or older continues to increase, with a concomitant increase in the need for effective management of menopausal symptoms in this group. All postmenopausal women, including those with HIV infection, should undergo routine health screening, including Pap smears and screening for STDs, breast cancer, colon cancer, osteoporosis, cardiovascular risk factors, and depression. Evidence suggests that several important interactions may occur between HIV infection and menopause, and primary care physicians may be better able to assist women with HIV experiencing complications of menopause if they have an understanding of this potential interplay. Several potential associations that may be useful to consider include:
Current evidence supports the use of hormone replacement therapy for relief of menopausal symptoms, especially vasomotor effects. However, there are no available data demonstrating safety in the HIV population.