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Special Considerations in the Management of HIV in Women, Including During Conception and Pregnancy

Joseph J. Eron, Jr., MD
Program Director
Daniel R. Kuritzkes, MD
Program Director
Judith S. Currier, MD, MSc
Sigal Yawetz, MD
Released: May 21, 2020

Primary Care of Women With HIV

Because of the successes in identifying and treating HIV and the newer focus of treating all people with HIV infection, women with HIV are now living longer and are initiated on combination ART at higher CD4+ cell counts. As a result, standard female-focused primary care must be incorporated into the routine care of women with HIV. Clinicians must consider that many medical complaints made by women with HIV are not necessarily HIV related.

Immunizations
Routine clinical care should include immunizations, and vaccine recommendations are similar between patients with and without HIV. However, HIV can change the efficacy and/or safety of vaccines, and the benefits of vaccination should be weighed against the risks to the patient.[8] For example, preliminary data regarding the human papillomavirus (HPV) vaccine indicate that this vaccine is both safe and immunogenic in young women with HIV.[9-12] However, the varicella virus vaccine and zoster vaccine live are contraindicated for patients with CD4+ cell counts < 200 cells/mm3.[13,14]

The following vaccinations are recommended[13] and have been outlined by the CDC[15]:

  • Hepatitis A adult vaccine (2 doses within 1-1.5 years) for individuals without detectable immunity and at risk for acquiring hepatitis A (eg, from injection drug use, chronic hepatitis B or C infection, or other chronic liver diseases)
  • Hepatitis B adult vaccine (3 doses within 6 months) for individuals without indication of past or present infection
  • Pneumococcal 13-valent conjugate vaccine (1 dose) and pneumococcal 23-polyvalent vaccine (1 dose administered ≥ 8 weeks after pneumococcal 13-valent conjugate vaccine), with pneumococcal 23-polyvalent vaccine booster every 5 years, not to exceed 3 lifetime doses[13]
  • Influenza virus vaccine, inactivated every fall for women who are not allergic to eggs; the nasal spray influenza virus vaccine, live should not be administered
  • Tetanus/diphth/pertussis (Tdap) adult/adolescent (1 dose) with tetanus toxoid and diphtheria booster (Td) every 10 years; administer 1 dose of Tdap to pregnant women during each pregnancy (preferably at 27-36 weeks’ gestation) regardless of interval since prior Td or Tdap vaccination
  • Meningococcal conjugate vaccine (2 doses at least 2 months apart)
  • Measles/mumps/rubella virus vaccine (2 doses) is recommended in persons with HIV 12 months of age or older with CD4+ cell count ³ 200 cells/mm3; persons with perinatal HIV infection who were vaccinated with measles/mumps/rubella virus vaccine prior to initiating ART should be revaccinated (2 appropriately spaced doses) after establishing an effective ART regimen[16]; measles/mumps/rubella virus vaccine is contraindicated during pregnancy
  • HPV vaccine (3 doses within 6 months) for women 9-26 years of age[13]
    • Although HPV vaccination is not recommended during pregnancy, no intervention is needed if vaccinated while pregnant and pregnancy testing is not needed before vaccination
  • Varicella virus vaccine (2 doses) is recommended for individuals with CD4+ cell count ³ 200 cells/mm3 and without a history of chicken pox or evidence of immunity serologically but is contraindicated for individuals with CD4+ cell count < 200 cells/mm3 and in pregnancy
  • Recombinant zoster vaccine (2 doses 2 months apart) is recommended for adults with HIV infection aged 50 years and older regardless of CD4+ cell count. Zoster vaccine live (1 dose) may be given if recombinant zoster vaccine is not available or because of intolerance, but only to patients with CD4+ cell counts ≥ 200 cells/mm3; a randomized phase II trial in patients with HIV on stable ART with CD4+ cell counts ≥ 200 cells/mm3 demonstrated the safety and immunogenicity of this vaccine in the indicated patient population.[17] Zoster vaccine live is contraindicated during pregnancy and recombinant zoster vaccine should ideally be delayed but no intervention is needed if vaccinated while pregnant and pregnancy testing is not needed before vaccination

The anthrax vaccine adsorbed and the smallpox vaccine should be avoided for all women with HIV infection.

Screening and Risk Factor Assessment
The Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents recommend testing for latent tuberculosis infection at the time of HIV diagnosis and annually thereafter in women with HIV with an ongoing risk for acquisition of tuberculosis. [13] Testing may be repeated in patients with HIV who had a baseline CD4+ cell count < 200 cells/mm3 after they achieved a CD4+ cell count ≥ 200 cells/mm3 on ART.[13] The WHO clinical guidelines recommend that patients with HIV in resource-constrained settings should be screened for tuberculosis at each clinical interaction by assessing potential symptoms of infection (coughing, fever, weight loss, and night sweats) and performing diagnostic tests if symptoms are present.

Although traditional screening methods include a tuberculin skin test, screening with newer tests such as interferon gamma release assays may provide advantages in patients with HIV, because results are obtained immediately and may be more accurate than traditional skin tests; however, these methods are still controversial.[18-22] Patients who were screened initially with a CD4+ cell count < 200 cells/mm3 should be rescreened after immune reconstitution. In individuals with a previous history of a positive tuberculin skin test, a symptom-focused questionnaire should be performed. Annual chest radiographs for tuberculosis in the absence of symptoms is not indicated.

HIV infection may increase the risk of cardiovascular disease, particularly in patients with other modifiable risk factors; therefore, screening patients with HIV for cardiovascular disease risk factors is important.[23,24] Traditional modifiable risk factors for cardiovascular disease include cigarette smoking, hypertension, hyperlipidemia, diabetes, and obesity. The most recent guidelines for managing blood cholesterol identify 4 risk groups of patients for whom moderate-intensity to high-intensity statin therapy is recommended and advise clinicians to use risk assessment tools to inform statin therapy decisions rather than target lipoprotein values.[25] Risk factors should be addressed at each physician visit and behavioral and pharmacologic interventions initiated as appropriate.[26] Commonly used algorithms to predict risk of cardiovascular disease are broadly accurate in populations with HIV, although the Framingham, SCORE, D:A:D, and American College of Cardiology/American Heart Association algorithms all underestimate the presence of subclinical atherosclerosis and coronary heart disease in patients with HIV.[27-30]

The American Cancer Society recommends mammograms and self-breast examinations for women, regardless of HIV status, beginning at the age of 40 years.[31] A guideline panel expanded on and developed new recommendations for women at different defined levels of risk. This guideline states that screening magnetic resonance imaging is recommended for women with an approximately 20% to 25% or greater lifetime risk of breast cancer, including women with a strong family history of breast or ovarian cancer and women who were treated for Hodgkin disease.[32] The exact age at which to start mammograms is controversial. Primary care guidelines from the HIV Medical Association of the Infectious Diseases Society of America recommend an annual mammography for women aged 50 years or older, and performing individualized assessment of risk for breast cancer followed by discussion of the risks and benefits screening mammography with women between 40 and 49 years of age.[33] There are no data to suggest that women with HIV are at a higher risk for developing breast cancer compared with women who do not have HIV.[34]

Psychosocial stressors should be evaluated on a regular basis in women with HIV. A multidisciplinary team that incorporates social services, mental health, and case management is often required to maintain ongoing clinical care and medication compliance in this population.[35,36]

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