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Practice bulletins > #167 Gynecologic Care for Women and Adolescents with Human Immunodeficiency Virus > Flashcards

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

1
Q

What % of US cases of HIV are women?

A

24%

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2
Q

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

A

75%

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3
Q

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

A

23%

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4
Q

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

A

2%

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5
Q

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

A

78%

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6
Q

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

A

During reproductive years

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7
Q

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

A

True

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8
Q

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

A

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

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9
Q

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

A

6 medication classes

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10
Q

What birth defect(s) are associated with Efavirenz?

A

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

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11
Q

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

A

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

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12
Q

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

A

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

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13
Q

What type of medication is Nevirapine?

A

Nonnucleoside reverse transcriptase inhibitor

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14
Q

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

A

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

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15
Q

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

A

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

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16
Q

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

A

Continue throughout lifetime, do not stop screening

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17
Q

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

A

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

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18
Q

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

A

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

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19
Q

How should you manage HIV positive patient with LSIL pap?

A

Colposcopy

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20
Q

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

A
  1. reflex to HPV, if positive do colpo

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

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21
Q

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

A

Repeat cytology in 6-12 mo, no HPV testing

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22
Q

Why are women with HIV screened earlier for cervical cancer?

A

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

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23
Q

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?

A

Same incidence

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24
Q

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

A

Imiquimod, podofilox, sinecatechins

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25
Q

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

A

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

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26
Q

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

A

Biopsy to ensure vulvar intreepithelial neoplasia or cancer is not present

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27
Q

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

A

True

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28
Q

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

A

True

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29
Q

How should you screen HIV positive women for anal cancer?

A

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
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30
Q

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

A

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

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31
Q

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

A

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

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32
Q

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

A

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

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33
Q

What are recommendations regarding STI screening in HIV positive women?

A

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

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34
Q

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

A

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

Same treatment regimens

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35
Q

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

A

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

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36
Q

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

A

No

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37
Q

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?

A

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

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38
Q

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

A

40-80%

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39
Q

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

A

No

40
Q

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

A

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

41
Q

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?

A

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

42
Q

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

A

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

43
Q

How often should you test HIV positive patient for syphilis?

A

At entry to care and at least annually thereafter

44
Q

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?

A

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

45
Q

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

A

More likely to have multiple ulcers

46
Q

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

A

More often have concomitant genital ulcers

47
Q

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

A

No

48
Q

How do you define treatment failure for syphilis treatment?

A

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

49
Q

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

A

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

50
Q

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

A

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

51
Q

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

A

No

52
Q

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

A

3 months, due to high prevalence of reinfection

53
Q

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?

A

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

54
Q

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

A

At entry to care and at least annually thereafter.

55
Q

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

A

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

56
Q

How long after treatment for trichomonas should you rescreen?

A

3 months

57
Q

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

A

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

58
Q

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

A

Antiretroviral therapy with drugs with activity against both viruses

59
Q

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

A

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

60
Q

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

A

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

61
Q

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

A

No

62
Q

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

A

True

63
Q

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

A

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

64
Q

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

A

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

65
Q

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

A

Antiretroviral preexposure prophylaxis (PrEP)

66
Q

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

A

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

67
Q

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

A

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

68
Q

What is serosorting?

A

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

69
Q

What are risks of practicing serosorting?

A

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)

70
Q

What is seropositioning?

A

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

71
Q

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

A

80%

72
Q

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

A

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

73
Q

Can women with undetectable plasma loads of HIV still transmit?

A

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

74
Q

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

A

0.46 compared with 5.64

75
Q

What is the medication in antiretroviral preexposure prophylaxis for HIV?

A

Oral tenofovir disoproxil fumarate and emtricitabine

76
Q

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

A

Decrease by 75-84%

77
Q

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

A

Two or more times in the past year

78
Q

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

A

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

79
Q

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

A

18%

80
Q

Is HIV infection a contraindication to any type of contraceptive?

A

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

81
Q

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

A

No

82
Q

Through which pathways are hormonal contraceptives primarily metabolized?

A

Sulphate and glucuronide conjugation in the liver and cytochrome P450 enzymes

83
Q

How does efavirenz affect combined hormonal contraceptive levels?

A

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

84
Q

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

A

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

85
Q

How do fosamprenavir and hormonal contraceptives affect each other?

A

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

86
Q

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

A

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

87
Q

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

A

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

88
Q

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

A

MEC category 1 for continuation, MEC category 2 for initiation

89
Q

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

A

None

90
Q

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

A

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

91
Q

Is sterilization contraindicated in HIV-infected patients?

A

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

92
Q

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

A

Below the limit of detection

93
Q

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

A

True

94
Q

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

A

Artificial insemination

95
Q

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

A

26%

96
Q

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

A

Cognitive impairment. Anxiety, depression, ADHD, PTSD

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