Serodiscordant Couples
Thus far, there is limited standardization or consensus on how and when to provide counseling, testing, and prevention strategies for women who are involved in HIV serodiscordant relationships. However, most experts recommend that patients whose partners are HIV positive should be tested for HIV infection annually and encouraged to use effective prevention strategies such as the male or female condom.
Screening and treatment for sexually transmitted diseases should be done annually as coinfection can increase the risk of HIV transmission. In one of the studies demonstrating an impact of STD treatment – a randomized trial conducted more than 15 years ago in rural Tanzania – improved STD education and treatment reduced HIV incidence by about 40% (Lancet 1995;346:530-6).
In cases in which an unplanned sexual encounter with an HIV-positive partner occurs without protection, postexposure prophylaxis should be considered and given as soon as the event is identified, preferably within 48 hours. The CDC's recommendations for the use of antiretroviral postexposure prophylaxis, issued in 2005, call for a 28-day course of HAART (MMWR 2005;54[RR02]:1-20)
Decisions about the optimal postexposure therapy involve various factors, including the partner's antiretroviral history, adherence to the regimen, and most recent viral load. We may need to counsel patients, however, that having undetectable virus in the blood does not necessarily mean there will not be any virus in the genital tract. Discrepancies between serum and genital viral load have been reported among HIV-infected men and women on HAART.
If a woman engages in unprotected sex with a male of unknown serostatus, she can request postexposure prophylaxis. In this case, she should be counseled about the risks and benefits of postexposure HAART, as she may expose herself to unnecessary toxicities.
When faced with these situations we can obtain guidance from, or work in partnership with, the infectious disease provider who is managing the HIV-infected partner, or we can contact state or national phone lines for linkage to immediate care. Some health departments have established nonoccupational postexposure prophylaxis programs in their jurisdictions. Overall, it is important that we be aware of the availability of postexposure HAART and its possible risks and benefits.
In the near future, a woman whose partner is HIV positive should be able to benefit from antiretroviral microbicides used before or after intercourse. In the double-blind, randomized, and well-publicized CAPRISA (Centre for the AIDS Programme of Research in South Africa) 004 trial, a 1% vaginal gel formulation of tenofovir reduced HIV acquisition by approximately 39% overall and by 54% in women with high adherence to the protocol for gel application (Science 2010;329:1168-74). Another phase III trial of tenofovir is ongoing.
The field of safe reproduction for HIV serodiscordant couples also is advancing, such that women and their partners have various options for conceiving with minimal risk of transmitting the infection.
A large body of evidence suggests that reproductive technology – that is, sperm washing and artificial insemination – can help HIV-affected couples safely conceive, and the results of further CDC-sponsored research aimed at evaluating outcomes in couples who have used these techniques to conceive are expected soon. For many couples, however, such technologies are economically inaccessible.
Experts are looking at periconception preexposure prophylaxis as a potential strategy for preventing HIV transmission in couples trying to conceive. Under this approach, the seronegative partner would take antiretroviral drugs during periods of attempted conception, with the goal of preventing initial viral replication. Clinical trials evaluating its safety and efficacy are ongoing.
Other components of a risk-reduction program should include suppressive antiretroviral therapy for the infected partner (who may yet be eligible for such therapy under current recommendations for CD4 cell count), screening and pretreatment for other sexually transmitted infections, and unprotected sexual intercourse that is limited to times of peak fertility (AIDS 2010;24:1975-82).
Perinatally Infected Women
An increasing number of perinatally infected adolescents has been identified and engaged in care throughout the United States. This population is unique in that many were initially exposed to monotherapy or dual antiretroviral regimens and thus have developed resistance to several antiretroviral regimens. In addition, their adherence to HAART is lower than required to avert failure on current regimens.
They are a population that presents a challenge to ob.gyns. because many have high-risk sexual behaviors, and when they become pregnant, they are at high risk for operative delivery due to inadequate viral suppression.
We recently reported on the pregnancy outcomes of 10 perinatally infected adolescents referred to the high-risk obstetric clinic at our institution and delivered between 1997 and 2007. Neonatal outcomes were generally favorable, but these young women had a high rate of operative delivery (62%, compared with our institutional rate of 33%) due to the failure to achieve undetectable viral load (Am. J. Obstet. Gynecol. 2009;200:149.e1-5).