Our goals for these women should therefore include supporting and counseling on treatment adherence and on the selection of well-tolerated HAART regimens that can rapidly suppress viral load. We should also minimize the use of operative deliveries when feasible to avert compromise of their future reproductive health, and provide adequate contraceptive counseling to prevent unplanned pregnancies. We also must engage the partners of these young women in HIV prevention strategies and HIV testing (in our cohort, most of the sexual partners were seronegative males) and work with them in preventing the acquisition of other sexually transmitted infections. Abnormal cervical cytology and STIs affected 80% of the patients in our cohort, and high rates of STIs have been reported in other cohorts of HIV-infected adolescents.
Engaging the patients in care and viral suppression prior to conception and educating their partners to avert HIV acquisition will be among the highest priorities in years to come, especially since this group is more disenfranchised from the health care system and less likely to engage in pregnancy prevention and planning.
Dr. Bardequez said she had no relevant financial disclosures.
Arlene D. Bardeguez, M.D., M.P.H.
Source Courtesy Dr. Arlene D. Bardequez
Source Elsevier Global Medical News
Source Elsevier Global Medical News
HIV and Nonpregnant Women
Since the beginning of the HIV/AIDS epidemic in the 1980s, women have been affected with this dreaded disease. Many have been at risk of acquiring the virus, many have become infected, and some consequently have been at risk of transmitting the virus to their offspring.
Ob.gyns. have played a major role in the dramatic decrease in mother-to-child transmission since its peak in 1992; prenatal screening followed by the use of antiretroviral therapy in women found to be HIV infected has reduced the risk of HIV transmission from a woman to her child to less than 2%.
Among nonpregnant women, our frequency of HIV testing has been variable, depending, for many of us, on the prevalence of HIV/AIDS in our communities and on our knowledge and/or perception of each patient's risk level.
In recent years, this selective approach to testing has been deemed faulty. It is an approach that has been subject to our own biases of risk and to misperceptions of many of the women we care for. Moreover, a risk-based approach has increasingly conflicted with the changing face of AIDS/HIV infection – most notably, the rise in heterosexual transmission and the fact that 1 in 5 infected individuals (including our patient's sexual partners) are estimated to be unaware of their infection.
Studies have shown that many women who are found to be HIV positive did not consider themselves to be at risk. Had we seen these women, we might not have considered them to be at risk either. According to the most recent HIV Surveillance Report from the Centers for Disease Control and Prevention, 30% of HIV-positive women were tested for HIV late in their illness (that is, diagnosed with AIDS within 1 year of testing positive). Had they been diagnosed earlier, these women could have had years added to their lives with the early and ongoing use of highly active antiretroviral therapy.
For these and other reasons, there are significant public health advantages to the recommendation issued by the CDC 5 years ago that health care providers routinely test (with patient notification and an opportunity to decline) all patients aged 13–64 years.
As providers for women of all ages, it is important that we are aware of changing trends and issues in the HIV epidemic and that we are attentive to the CDC's recommendations. It is for this reason that I have invited Dr. Arlene D. Bardeguez to address the role that the ob.gyn. plays in HIV prevention and testing in nonpregnant women.
Dr. Bardeguez serves as professor in the department of obstetrics, gynecology and women's health and director of HIV services at the New Jersey Medical School, Newark, N.J. Her special interest and expertise in HIV-infected women is evident in her clinical work and patient care, her research and writing, her teaching, and her work in the policy arena.
Here, she explains why HIV prevention strategies, including HIV pre- or postexposure prophylaxis, should become part of our routine clinical care. She also details how we can care for perinatally infected adolescents and how we must address the risks faced by our older patients. As providers of women's health through the age spectrum, she explains, we have an important role to play in the prevention of HIV acquisition and transmission.