#167 Gynecologic Care for Women and Adolescents with Human Immunodeficiency Virus

Question 1

What % of US cases of HIV are women?

Answer 1

24%

Question 2

Heterosexual contact is responsible for what % of HIV transmission among women in the US?

Answer 2

75%

Question 3

Injection drug use accounts for what % of HIV transmission among women in the US?

Answer 3

23%

Question 4

Perinatal infection accounts for what % of HIV transmission among women in the US?

Answer 4

2%

Question 5

African American and Hispanic women combined account for what % of HIV-infected women in the US?

Answer 5

78%

Question 6

During what stage of life are most women with HIV diagnosed, in the US?

Answer 6

During reproductive years

Question 7

True or false. Patients with HIV treated by a health care practitioner with expertise in HIV prolongs the life of HIV-infected individuals?

Answer 7

True

Question 8

At what CD4+ lymphocyte count should you start antiretroviral therapy?

Answer 8

Initiation is recommended for all adults and adolescents with HIV regardless of CD4+ lymphocyte counts

Question 9

How many classes of FDA approved antiretroviral agents are there for treated HIV?

Answer 9

6 medication classes

Question 10

What birth defect(s) are associated with Efavirenz?

Answer 10

Possible increased risk of CNS birth defects, although recent prospective data have not detected increased risk. Concern is for neural tube defects, which is restricted to the first 5-6 wks of pregnancy

Question 11

In women with HIV who take efavirenz who present for preconception counseling, should you change their meds?

Answer 11

Yes, antiretroviral therapy that do not contain efavirenz should be strongly considered

Question 12

In women with HIV who take efavirenz who present for initial prenatal visit at 8wks, should you change their meds?

Answer 12

No. Efavirenz can be continued in patients who present for care after 6wks provided the regimen is achieving virologic suppression, because risk of neural tube defect is restricted to first 5-6 wks of pregnancy

Question 13

What type of medication is Nevirapine?

Answer 13

Nonnucleoside reverse transcriptase inhibitor

Question 14

What is the significant clinical risk/side effect of Nevirapine use? Who is greatest at risk for this?

Answer 14

Increased risk of potentially severe and life-threatening liver toxicity in antiretroviral-naive individuals. Risk greatest in women with CD4+ counts >250cells/mm^3 or elevated baseline transaminase levels

Question 15

In women with HIV, when should you start cervical cancer screening?

Answer 15

Within 1 year of onset of sexual activity or, if already sexually active, within first year after HIV diagnosis, but no later than 21yo

Question 16

When should you stop cervical cancer screening in HIV positive women with adequate normal screening?

Answer 16

Continue throughout lifetime, do not stop screening

Question 17

With what frequency should you perform cervical cancer screening in HIV positive women <30?

Answer 17

Three consecutive negative annual cervical cytology screenings, then can do q3 years cytology

Question 18

With what frequency should you perform cervical cancer screening in HIV positive women 30+?

Answer 18

If cytology only: Three consecutive negative annual cervical cytology screenings, then can do q3 years cytology
If cotesting: one negative cotest, next screening in three years

Question 19

How should you manage HIV positive patient with LSIL pap?

Answer 19

Colposcopy

Question 20

Next step in management for 21yo+ woman with HIV with ASCUS pap?

Answer 20

1. reflex to HPV, if positive do colpo

2. if no HPV testing available, repeat cytology in 6-12mo

Question 21

Next step in management for <21yo woman with HIV with ASCUS pap?

Answer 21

Repeat cytology in 6-12 mo, no HPV testing

Question 22

Why are women with HIV screened earlier for cervical cancer?

Answer 22

Sexually active adolescents with HIV appear to have high rate of progression of abnormal cytology

Question 23

Women with HIV who receive regular cervical cancer screening and recommended follow up have increased, decreased, or the same incidence of invasive cervical cancer compared to HIV negative women?

Answer 23

Same incidence

Question 24

What are recommended patient-applied regimens for external anogenital warts per CDC?

Answer 24

Imiquimod, podofilox, sinecatechins

Question 25

What are recommended provider-administered regimens for external anogenital warts per CDC?

Answer 25

Cryotherapy with liquid nitrogen or cryoprobe, surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser, or electrosurgery, or trichloroacetic acid or bichloroacetic acid

Question 26

What should you do if anogential warts fail to respond to standard therapy?

Answer 26

Biopsy to ensure vulvar intreepithelial neoplasia or cancer is not present

Question 27

True or false: women with HIV have higher rates of high-grade anal intrepithelial neoplasia and anal cancer compared to general population?

Answer 27

True

Question 28

True or false: women with HIV have higher rates of vaginal, vulvar, and perianal neoplasia compared to general population?

Answer 28

True

Question 29

How should you screen HIV positive women for anal cancer?

Answer 29

No national recommendations for anal cancer screening. - Annual digital rectal exam may be useful to detect masses that could be anal cancer - Screening should not be performed unless referral for high-resolution anoscopy is available to evaluate and treat abnormal findings

Question 30

How does the diagnosis and treatment of bacterial vaginosis differ between HIV-infected and non-HIV-infected women?

Answer 30

Diagnosis and treatment unchanged. BV appears to be more prevalent and persist

Question 31

For which HIV-positive patients is long-term prophylacitc therapy with fluconazole for prevention of vulvovaginal candidiasis indicated?

Answer 31

Not recommended for routine primary prophylaxis unless the recurrences are frequent or severe

Question 32

What should be monitored in patients in whom you anticipate oral azole therapy for more than 21 days?

Answer 32

Consider periodic monitoring of LFTs, especially in patients with other hepatic comorbidities

Question 33

What are recommendations regarding STI screening in HIV positive women?

Answer 33

Screened at entry to care and annually for gonorrhea and chlamydia, syphilis, and trichomoniasis. Screening for HCV at entry to care.

Question 34

How is chancroid different in HIV pos patients compared to HIV neg?

Answer 34

More likely to experience treatment failure (need to be monitored closely) and have lesions that heal slowly. Same treatment regimens

Question 35

Do HIV positive women with HSV requiring suppression or episodic therapy require different regimens than HIV negative women?

Answer 35

CDC recommends treatments with higher doses, more frequent administration, and longer courses

Question 36

Does suppression therapy for HSV in HIV positive women decrease the risk of transmission of HSV to susceptible partners?

Answer 36

No

Question 37

Can you offer HSV type-specific serologic testing to HIV-infected women with unknown HSV infection status? If so, what do you do with the results?

Answer 37

You can offer testing and offer suppressive therapy to women with HSV-2

Question 38

What percentage of HIV-infected individuals are co-infected with HSV-2 in US and Europe?

Answer 38

40-80%

Question 39

Does HSV suppression therapy decrease transmission of HIV in those co-infected?

Answer 39

No

Question 40

How does oral antiviral agents (against HSV) affect symptoms/shedding/viral load/transmission of HSV and HIV in coinfected individuals?

Answer 40

Decreases genital ulcers Decreases genital HSV-2 shedding Decreases HIV genital shedding Decreases plasma HIV viral load DOES NOT decrease transmission of HSV or HIV

Question 41

Do patients with HIV and granuloma inguinale require different treatment regimens than people without HIV? What should you add if improvement does not occur in first few days of treatment?

Answer 41

Treated the same. Additional of parenteral gentamicin can be considered if improvement does not occur in first few days of treatment?

Question 42

Do women with HIV and lymphogranuloma venereum require different treatment than HIV negative patients? Any difference in clinical course?

Answer 42

Same treatment. Co-infected patients may have a delay in resolution of may require prolonged therapy

Question 43

How often should you test HIV positive patient for syphilis?

Answer 43

At entry to care and at least annually thereafter

Question 44

Does interpretation of treponemal and nontreponemal serologic test vary between patients with HIV infection and without? Does it change rates of false neg or pos?

Answer 44

No change in interpretation. May be associated with higher risk of false-positive nontreponemal serologic test results, so all reactive (positive) test results must be confirmed with a treponema-specific test

Question 45

Compared with non-HIV-infected patients, how are HIV-infected patients more likely to present with primary syphilis?

Answer 45

More likely to have multiple ulcers

Question 46

Compared with non-HIV-infected patients, how are HIV-infected patients more likely to present with secondary syphilis?

Answer 46

More often have concomitant genital ulcers

Question 47

Does treatment for syphilis vary between non-HIV-infected individuals and HIV-infected individuals?

Answer 47

No

Question 48

How do you define treatment failure for syphilis treatment?

Answer 48

Signs or symptoms that persist or recur or individuals who have a sustained [greater than 2 wks] fourfold increase or greater in titer

Question 49

How should you follow HIV-infected patients being treated for syphilis (to evaluate for treatment failure)

Answer 49

Evaluate clinically and serologically at 3, 6, 9, 12, and 24 months after therapy

Question 50

For what additional reason should women with HIV be treated promptly for gonorrhea or chlamydia?

Answer 50

Presence of gonorrhea or chlamydia increases HIV shedding, which decreases with treatment

Question 51

Does the treatment regimen for gonorrhea/chlamydia differ between HIV-infected women and non infected?

Answer 51

No

Question 52

How long after gonorrhea or chlamydia infection treatment should patients be retested?

Answer 52

3 months, due to high prevalence of reinfection

Question 53

Does the treatment for pelvic inflammatory disease differ between HIV-infected women and non HIV-infected? What are HIV-infected women possibly at increased risk for?

Answer 53

Duration and choice of antimicrobial regimens do not differ. Presentation and clinical course do not appear to differ, but women with HIV may have more frequent TOAs

Question 54

How often should you screen a women with HIV for trichomonas?

Answer 54

At entry to care and at least annually thereafter.

Question 55

Does the treatment for trichomonas differ between HIV-infected patients and non HIV infected patients?

Answer 55

Yes. In non infected, can do single dose regimen. In HIV-infected individuals recommendation is to treat with 1 week course of metronidazole

Question 56

How long after treatment for trichomonas should you rescreen?

Answer 56

3 months

Question 57

How should you manage HIV-infected patients without prior Hepatitis B vaccine?

Answer 57

Vaccinate with Hep B vaccine or combo hep A and B vaccine. Because magnitude and duration of vaccine immunogenicity are lower with HIV-infection, should test Hep B SAb 1-2mo after 3rd vaccine dose

Question 58

How should you manage patients infected with both HIV and Hepatitis B (broadly)?

Answer 58

Antiretroviral therapy with drugs with activity against both viruses

Question 59

How often should you test HIV-infected individual for Hepatitis C?

Answer 59

At entry to care and annually for at-risk seronegative individuals

Question 60

Does the treatment for pediculosis pubis or scabies (ectoparasites) differ between HIV-infected and non-infected individuals? Does clinical presentation differ?

Answer 60

Same treatment. HIV-infected individuals are at increased risk of crusted scabies, which should be managed in consultation with a specialist

Question 61

Does the evaluation and treatment for menstrual disorders differ for women with HIV compared to those not infected?

Answer 61

No

Question 62

True or false: women with HIV have higher rates of prolonged amenorrhea

Answer 62

True

Question 63

Does the treatment for menopausal symptoms differ for HIV-infected women?

Answer 63

Still can use HRT, however, may need higher doses due to drug interactions with antiretrovirals. Cannot use hormones with fosamprenavir (decreases antiretroviral levels)

Question 64

Does HIV infection change screening, risk, management of ospteopenia/porosis, fragility fractures?

Answer 64

Low bone mineral density is more prevalent amont HIV infected women. Significantly more fragility fractures. No change in recommendation for treatment. Screening to be considered at age 50 if one or more risk factors

Question 65

How can partners of women with HIV reduce the risk of transmission?

Answer 65

Antiretroviral preexposure prophylaxis (PrEP)

Question 66

What methods can HIV-discordant couples use to reduce risk of sexual HIV transmission?

Answer 66

Latex and polyurethane male or female condoms. Dental dams or other physical barriers for oral sex. Sexual positioning that lowers partner's risk. Mutual masturbation, digital penetration, clean sex toys, avoiding exposure to bodily fluids, water-based spermicides/lubricants (compatible with latex), reduce # sexual partners, avoid contact with body fluids after invasive oral/dental procedures

Question 67

What sexual positioning is lowest to highest risk of HIV transmission?

Answer 67

For HIV negative partner: insertive fellatio, receptive fellatio, insertive penile-vaginal sex, receptive penile-vaginal sex, insertive anal sex, receptive anal sex

Question 68

What is serosorting?

Answer 68

Practice of limiting unprotected sex to partners believed to have the same HIV status

Question 69

What are risks of practicing serosorting?

Answer 69

Can result in HIV transmission is assumptions about partner's HIV status are incorrect or may result in acquiring STIs and, more rarely, can lead to superinfection (acquiring new HIV strain)

Question 70

What is seropositioning?

Answer 70

Practice of modifying sexual activity based on beliefs about partner's HIV infection status and using sexual positioning that lowers a partner's risk of acquiring HIV

Question 71

Consistent use of male condoms results in what % reduction in risk of HIV transmission among HIV serodiscordant couples?

Answer 71

80%

Question 72

What spermicides should be avoided in women with HIV and why?

Answer 72

Spermicides that contain nonoxynol-9 because they may increase risk of transmission by disrupting the genital epithelium

Question 73

Can women with undetectable plasma loads of HIV still transmit?

Answer 73

Yes. Virus can be detected in semen, rectal secretions, female genital secretions, and pharynx of HIV-infected patients with undetectable plasma viral loads

Question 74

What is the rate of HIV transmission per 100 person-years from HIV infected partners treated with antiretroviral therapy to those without?

Answer 74

0.46 compared with 5.64

Question 75

What is the medication in antiretroviral preexposure prophylaxis for HIV?

Answer 75

Oral tenofovir disoproxil fumarate and emtricitabine

Question 76

How much does use of preexposure prophylaxis reduce the risk of HIV transmission in serodiscordant heterosexual couples?

Answer 76

Decrease by 75-84%

Question 77

After how many occurrences of a non infected partner of an HIV infected person taking nonoccupational postexposure prophylaxis should you encourage preexposure prophylaxis?

Answer 77

Two or more times in the past year

Question 78

Within how many hours/days after inadvertent sexual or parenteral HIV exposure should postexposure prophylaxis be administered? How long should regimen be administered for?

Answer 78

Within 72 hours, two or three antiretroviral medications continued for 28 days

Question 79

What is the typical failure rate of condoms (pregnancy) over 1 year?

Answer 79

18%

Question 80

Is HIV infection a contraindication to any type of contraceptive?

Answer 80

No, but care needs to be taken regarding drug-drug interactions

Question 81

Does hormonal contraceptive use increase the risk of disease progression or death in women with HIV?

Answer 81

No

Question 82

Through which pathways are hormonal contraceptives primarily metabolized?

Answer 82

Sulphate and glucuronide conjugation in the liver and cytochrome P450 enzymes

Question 83

How does efavirenz affect combined hormonal contraceptive levels?

Answer 83

May lead to decrease in contraceptive levels, but co-administration of these meds are still considered safe

Question 84

How does ritonavir-boosted and unboosted protease inhibitors affect contraceptive hormone levels?

Answer 84

May have decreased contraceptive levels. These methods are still generally considered safe for use. Exception is fosamprevanir.

Question 85

How do fosamprenavir and hormonal contraceptives affect each other?

Answer 85

Hormonal contraceptives may lead to decreased efficacy of the antiretroviral drug (MEC category 3)

Question 86

Which HIV antiretroviral agents may decrease the efficacy of the contraceptive implant? What MEC category?

Answer 86

Efavirenz, ritonavir-boosted protease inhibitors, fosamprenavir, nelfinavir. MEC category 2. They may slightly decrease efficacy, but still remains highly effective

Question 87

Which HIV antiretroviral agents may decrease the efficacy of depot medroxyprogesterone acetate?

Answer 87

Theoretical concern with fosamprenavir (MEC 2). No other drug interactions have been demonstrated

Question 88

What is the MEC category for IUD insertion and continuation for HIV-infected women who are not clinically well or not using antiretroviral drugs?

Answer 88

MEC category 1 for continuation, MEC category 2 for initiation

Question 89

Which HIV antiretroviral agents may affect efficacy of LNG-IUD?

Answer 89

None

Question 90

Does a women having HIV affect what emergency contraception can be offered?

Answer 90

No. Only known study about use of EC in women on antiretroviral therapy showed decrease in LNG levels when given with efavirenz. No studies of interactions with ulipristal

Question 91

Is sterilization contraindicated in HIV-infected patients?

Answer 91

No. Optimize patient's health before elective surgery. Decision should be voluntary and noncoerced.

Question 92

At what HIV viral load is it recommended for women to become pregnant?

Answer 92

Below the limit of detection

Question 93

True or false. HIV positive women should be on antiretroviral therapy at the time of conception?

Answer 93

True

Question 94

What is the safest way for an HIV-infected woman to become pregnant while minimizing risk of HIV transmission to partner?

Answer 94

Artificial insemination

Question 95

What % of individuals 13-24yo with HIV were infected perinatally?

Answer 95

26%

Question 96

Adolescents and young adults who have HIV (either behaviorally or perinatally infected), have higher rates of what mental health problems?

Answer 96

Cognitive impairment. Anxiety, depression, ADHD, PTSD