Human immunodeficiency virus (HIV) is a single-stranded enveloped RNA retrovirus that was first described in the 1980s and is known for its severity of systemic immune dysregulation and associated opportunistic infections. It is transmitted through contact with blood or bodily fluids, and it can be transmitted vertically, most often at the time of delivery. Since the advent of antiretroviral therapy, the average life expectancy and natural course of HIV infection has improved notably.1
In 2019, just over 1 million adults and adolescents in the United States were living with the diagnosis of HIV.2 In the same year, the rate of new HIV diagnoses in the United States had stabilized at a rate of 13.2 new cases per 100,000 individuals.2 Among this cohort, individuals identifying as females at birth accounted for 19% of the total population living with HIV.2 Sexual contact was the most common route of transmission, followed by injection drug use—77% and 20%, respectively.2
It is important to note that the incidence and prevalence of HIV does not reflect the individuals who unknowingly are living with the disease. The disease burden associated with HIV infection and the availability of effective treatment modalities has led to the recommendation that all individuals undergo HIV screening at least once in their lifetime.3 Early identification of HIV infection is important to optimize the health of all individuals and future generations.
The interplay between high-risk sexual practices and the risk for HIV exposure and unintended pregnancy places the ObGyn at the forefront of HIV prevention and identification. Early diagnosis and standardized treatment with antiretroviral therapies have led to both a dramatic improvement in adult disease burden and a dramatic decrease in perinatal transmission.4,5 In 2019, perinatal transmission accounted for less than 1% of HIV transmission in the United States.2 This is a decrease of greater than 54% from 2014, which, again, emphasizes the role of the ObGyn in HIV management.6
Preconception care: Gynecologic screening, diagnosis, and management
The Centers for Disease Control and Prevention (CDC) recommends that an individual undergo HIV screening at least once in their lifetime.3 HIV screening algorithms have changed over the last 20 years to reduce the number of false-positive and/or false-negative results obtained through HIV antibody testing alone.7 HIV-1/2 antibody/antigen immunoassay is recommended as the initial screening test. If reactive, this should be followed by an HIV p24-specific antigen test. Reactivity for both the HIV-1/2 immunoassay and the HIV p24-specific antigen test confirms the diagnosis of HIV infection. However, if HIV p24-specific antigen testing is indeterminate or an acute HIV infection is suspected, an HIV nucleic acid test (NAT) should be performed.7,8
Upon a positive diagnosis, a multidisciplinary team approach is recommended to address the mental, social, and physical care of the patient. Team members should include an adult medicine clinician, an infectious disease clinician, an ObGyn, social services staff, and behavioral health support to achieve the goal of obtaining and maintaining the patient’s optimal health status.
TABLE 1 lists the recommended initial laboratory assessments that should follow a new diagnosis of HIV infection. Based on the laboratory results, the indicated vaccinations, antibiotic prophylaxis for opportunistic infections, and optimal combined antiretroviral therapy (cART) can be determined.9 The vaccinations listed in TABLE 2 should be up to date.10,11 Additionally, cervical cancer screening with cytology and human papillomavirus (HPV) testing and treatment should be performed in accordance with the 2019 American Society for Cervical Cancer Prevention (ASCCP) guidelines.12
Promptly initiating cART is of utmost importance; this decreases the rate of HIV transmission via sexual contact and decreases the rate of perinatal transmission.5,13 Results of the initial laboratory assessment, hepatitis B status, and desire for pregnancy/contraception should be considered when initiating cART.3,14,15
It is imperative to discuss sharing the positive diagnostic results with the patient’s partner. The CDC provides guidance for these discussions,16 which should address the use of preexposure prophylaxis (PrEP) if partner screening establishes partner serodiscordance (that is, HIV positivity in one partner and HIV negativity in the other partner). PrEP is a single pill approved by the US Food and Drug Administration (FDA) that combines tenofovir 300 mg and emtricitabine 200 mg daily17 and has been recommended since 2012.18-20 PrEP also should be considered in sexually active individuals who have higher-risk behaviors within an area with high HIV prevalence.18-21 Despite the CDC’s strong recommendations for PrEP use, lack of insurance coverage and high cost are barriers to universal use. The National Alliance of State and Territorial AIDS Directors (NASTAD) provides a list of patient and copayment assistance programs that can be found at the NASTAD website: https://nastad.org/prepcost-resources/prep-assitance-programs.
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