Sexual and reproductive health + HIV Flashcards by Yvonne McFarlane

What proportion of HIV infections acquired through heterosexual contact are in women?

63%

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On average, which of heterosexual women or men are infected/diagnosed at an earlier age?

Women

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What proportion of all HIV infection in the UK are men (both MSM and heterosexual)?

> 60%

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How often should a sexual history be taken from PLWH?

6 monthly

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How often should syphilis testing be performed for PLWH?

with routine tests

consider 3 monthly

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How often should cervical smear be performed on women living with HIV?

annual

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How common is HCV infection through sexual contact?

1-3%

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Why should HCV infection be regularly screened for in PLWH?

Increase morbidity and mortality from HCV if co-infection with HIV

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How often should a full sexual health screen be offered, regardless of reported sexual activity?

annual

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Risk of HIV transmission man to woman, not on ART?

0.1-0.3% per act of sex

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Risk of HIV transmission woman to man, not on ART?

0.03-0.09% per act

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What potentially increases the viral load of HIV in genital secretions compared to plasma?

Co-infection with STI

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A prospective cohort study looking at serodiscordant couple in Uganda found no transmission of HIV at what viral load?

<1000copies/ml

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What alternative options are there for HIV positive men and HIV negative women if they do not wish to conceive naturally?

Insemination from sperm donor (BBV screen)
Sperm washing
Adoption - previously difficult

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Explain sperm washing

Semen is centrifuged to separate spermatozoa from seminal fluid and non-sperm cells and then inseminated into female partner at time of ovulation

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Why does sperm washing work to reduce risk of HIV transmission?

Sperm do not carry HIV

Seminal fluid and non-germinal cells do but they are separated out

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If a couple have fertility difficulties, what can sperm washing be combined with?

Ovulation induction
IVF
Intracytoplasmic sperm injection

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What percentage of centrifuged semen will contain detectable viral load?

3-6% therefore testing of sample before insemination is expected

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Prior to either natural conception or sperm washing what baseline assessment should be made of the couple?

Sexual health screen
Genital lesions/infections treated
Semen analysis
Endocrine profile of woman
Baselin pelvic scan in early follicular phase
Non-invasive assessment tubal patency

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If a woman is anovulatory, what medications are preferred to induce ovulation?

Clomifene

Injectable gonadotrophins

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What is the association between HIV infection and semen parameters on analysis?

Total sperm count and motility affected by CD4 cell count

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What is the association between HIV infection and pregnancy outcome from intrauterine insemination?

Higher pregnancy rate if male viral load <1000 and on ART

No correlation with CD4 cell count

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Why do HiV positive women have reduced fertility?

Reduced ovarian reserve

Tubal damage

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What is the rationale for undertaking fertility Assessment before attempting conception, natural or otherwise?

To avoid unnecessary exposure to HIV

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What pre-conception guidance should be given to women with HIV?

Switch to ART that is not teratogenic eg efavirenz Start ART by third trimester Involvement of specialist obstetric team

Which medications have been implicated in erectile dysfunction?

``` Anti-depressants Anti-psychotics Anabolic steroids Lipid-lowering agents Alcohol ```

What is first line treatment for erectile dysfunction? What is a contraindication for use?

oral PDE5 inhibitors - sildenafil etc Nitrate therapy contraindication Note interaction with ritonavir

What is the potential association between taking PDE inhibitors and high-risk sexual behaviour?

Unlikely direct but people who take PDE5Is often take other substances such as alcohol or recreational drugs that are associated with higher-risk

Other than erectile dysfunction what other sexual dysfunctions may affect men?

ejaculatory problems loss of libido arousal problems

What might cause 'retarded ejaculation' in HIV positive men?

ARV induced peripheral neuropathy

What might cause loss of sexual desire in HIV positive men?

Mainly psychological | Can be due to hormonal disturbance and hypogonadism

What is the relationship between HIV and HPV infection in women?

Higher prevalence cervical HPV infection Increased in lower CD cell count More persistent infection especially more oncogenic types

What impact does ART have on HPV infection?

Potential to facilitate clearance of HPV through improved immune function Induce regression or prevent development of CIN

What is the incidence of anus and anal canal cancers in general population in UK?

1. 2 per 100 000 men | 1. 7 per 100 000 women

What is the relative risk of anus and anal canal cancers in men and women with HIV?

37.9 men; 6.8 women

London rates of anal cancer in HIV positive cohort

60/100 000 | 120 times higher than control population

What is the survival data for people with HIV and anal cancer treated with chemo-radiotherapy?

47% overall 5 yr survival | 66% disease free 5 yr survival

What is a clear cause for anal cancers?

HPV oncogenic types | Current smoking - strong risk factor

How does HPV associated anal cancer arise?

Anal canal - transformational zone at junction anal squamous and rectal columnar epithelia (similar to cervix) High risk HPV infection of metaplastic reserve cells in transformational zone (higher propensity to oncogenic transformation) causes anal cancer

What proportion of men with HPV infection and normal baseline mucosa develop AIN?

24% develop high-grade squamous intra epithelial lesion/AIN2 or 3 over 4 years

What treatments are available for AIN?

Limited evidence/efficacy Topical HPV based treatments (possible) Electrosurgical - high recurrence but possible reduced risk of invasive cancer than if no treatment

Multiple HIV infections can occur at 3 distinct phases of HIV disease, what are they?

Simultaneous infection - 2 different strains infect same cell Sequential infection - after primary infection before antibodies produced, infected with a second strain Superinfection - re-infection once HIV has become chronic

What is the clinical significance of superinfection or dual infection?

Extremely rare for there to be clinical implication | Potential superinfection with a resistant virus

Describe the UK MEC 1-4 for contraception?

1 - no restriction for use 2 - advantage outweighs theoretical or proven risk 3 - Risk outweighs advantage 4 - unacceptable health risk

Male condoms - benefits, perfect and typical use failure rates

Contraception and protection against STI Perfect use 2-5% failure Typical use 15-21%

Why should N-9 spermicide not be used with condoms for people with HIV?

Mucosal irritant and can increase risk of HIV transmission

What UKMEC category are cervical caps or diaphragms for women with HIV? Why?

UKMEC 3 | Need to use N-9 spermicide

COCP - benefits, perfect and typical use failure rates

More effective than condoms alone Perfect 0.1% failure Typical 5% failure

What are the limitations of COC in women on ART?

Potential reduced contraceptive levels from drug-drug interactions No barrier protection

What are the potential DDIs between COC and ART?

PIs and NNRTIs metabolised by CYP3A4 therefore can reduce COCP levels

What other factor which may have an impact on metabolism via the liver may be present in a person HIV positive?

cirrhosis co-infection with HBV or HCV +/- alcohol use OR TB and therefore medication such as rifampicin

What is the UKMEC for ART + COC?

Non-enzme inducing - 2 | Enzyme inducing - 2 (but additional contraception advised)

Is the efficacy of combined contraceptive patch affected by ART?

Transdermal avoids first pass metabolism via liver | Unclear effect of enzyme inducers on efficacy

What is the UKMEC for CCP and HIV positive women?

No ART - 1 | ART - 2 (additional contraception advised if enzyme inducer)

How does the POP work?

Thickens cervical mucous and reduces endometrium | Desonorgestrel - inhibits ovulation

How does ART affect POP?

Potentially increases progestogen but more likely reduces it | UKMEC 2 + additional contraception

Can DMPA be offered to women with HIV?

Yes | DMPA metabolism not affected by liver enzyme inducing drugs

What potential risks/side effects of DMPA should be considered when prescribing?

Risk of low BMD with longterm use | Consider other risk factors including risk from ART

If a women opts for DMPA despite risk to bone health what should be performed?

Baseline DEXA

What effect does enzyme inducing ART have on the efficacy of the sub-dermal implant?

Potential increase metabolism and therefore reduced efficacy | UKMEC 2

Is the levonorgestrel IUS affected by liver enzyme-inducing drugs?

NO evidence to suggest

What is the levonorgestrel IUS main mode of action?

direct local effect on the endometrium preventing implantation

What is the copper IUD main mode of action?

Prevents fertilisation | Inhibits implantation

What is the first line emergency contraception for women with HIV?

CuIUD (especially if on enzyme inducing drugs)

If CuIUD is not an acceptable option for EC in women with HIV what advise should be given with the progestogen only EC?

Double the dose (if on enzyme inducing drugs)

Why are mineral oil-based lubricants with condom use discouraged?

Condom damage and increased breakage rate