Gynecological Care Guidelines for Women with HIV
is a press release issued by ACOG summarizing the new recommendations.
All women should be routinely screened for HIV,
and those found to be positive should undergo regular
monitoring of their gynecological health, including
tests for human papillomavirus (HPV) -- the cause
of cervical cancer -- and other sexually transmitted
diseases, according to guidelines issued last week
by the American College of Obstetricians and Gynecologists
(ACOG). Women should use condoms to prevent HIV
transmission, but adding a second birth control
method is more effective for preventing pregnancy.
HIV positive women who wish to become pregnant should
receive prompt prenatal care so they can receive
appropriate antiretroviral therapy (ART) to ensure
their own health and prevent mother-to-child transmission
of the virus.
Focus on Care for HIV+ Women as More
Live Longer with the Disease
DC -- November 22, 2010 -- As the number of women in the US
living with HIV/AIDS increases, ob-gyns will need to address
their unique contraception, preconception and prenatal care,
and general gynecologic requirements. In guidelines issued
today, the American College of Obstetricians and Gynecologists
(The College) emphasizes that ob-gyns will play a greater
role in providing routine gynecologic care to HIV-infected
women as these women live longer, healthier lives.
Approximately 27% of all HIV/AIDS cases in the US today are
among women, up from 7% in 1985. Black and Hispanic women
are disproportionately affected, accounting for 80% of all
HIV+ women today. Heterosexual
contact accounts for 72% of HIV transmission among women in
"Most of the women living with HIV today in the US are
in their prime reproductive years," said Hal C. Lawrence,
MD, vice president of practice activities for The College.
"As the number of women with HIV diagnoses increases,
ob-gyns will -- if they haven't already -- begin to see more
patients who are HIV-positive. These guidelines cover the
recommended health screenings, counseling, and routine gynecologic
care for these women."
The College recommends routine HIV screening for all women
ages 19-64, and targeted screening for women who have risk
factors that fall outside of this age range, for example,
sexually active or intravenous drug-using adolescents younger
than 19 years. Both the Centers for Disease Control and Prevention
(CDC) and The College recommend that all reproductive-age
women be screened for HIV at least once in their lifetime,
but there is no consensus on how often they should be retested.
Ob-gyns should review their patients' risk factors annually
to determine the need for retesting. Some women should be
offered repeat HIV screening at least annually, including
those who: are injection drug users; have sex partners who
are injection drug users or who are HIV+; exchange sex for
drugs or money; have been diagnosed with an STD in the past
year; or have had more than one sex partner since their last
The College recommends that HIV+ women be treated aggressively
for other sexually transmitted diseases (STDs). "Having
another STD in addition to HIV may increase the risk of transmitting
HIV to others," said Roxanne M. Jamshidi, MD, who assisted
in the development of the new guidelines. This is because
having other STDs increases shedding of the HIV virus. The
CDC recommends annual screening -- or more frequently, if
necessary -- for curable STDs such as syphilis, gonorrhea,
and chlamydia among sexually active women with HIV.
In general, women with HIV have a higher rate of bacterial
vaginosis and yeast infections than other women. "These
infections appear to be more common and more persistent among
women with HIV who are immunosuppressed," said Dr. Jamshidi.
The treatment for yeast infections for HIV+ women who have
compromised immune systems may require slightly longer treatment,
and those women with recurrent yeast infections may need long-term
medication to prevent future yeast infections.
The prevalence and persistence of human papillomavirus (HPV)
are more common among women with HIV, and both increase with
worsening immunosuppression. Thus, The College recommends
that HIV+ women have cervical screening twice in the first
year after being diagnosed and get screened annually thereafter
to avoid developing cervical cancer. Although women with HIV
who get the recommended screening don't have a higher rate
of cervical cancer than other women, they do, in general,
have higher rates of vaginal, vulvar, and perianal precancer.
They are also at increased risk for anal cancer compared with
the general population. Close scrutiny should be paid to these
areas in HIV+ woman, say the recommendations.
The Gardasil HPV vaccine has been proven safe in HIV+ children,
but whether it's effective in preventing HPV in women or girls
with HIV is unknown. The CDC's recommendations for HPV vaccination
of children and adolescents is the same, regardless of HIV
Dual contraception (using two different types of contraception
at the same time) is the optimal way for women with HIV to
reduce the risk of transmitting HIV and other STDs as well
as to prevent pregnancy. Although condoms are the only effective
method of avoiding STDs during intercourse, they are not the
most effective way to prevent pregnancy. "Women with
HIV will need to use condoms each time they have intercourse,
but they also need to use additional contraception to prevent
unintended pregnancy," said Dr. Jamshidi. Overall, hormonal
contraception is safe for HIV+ women, but combined (estrogen
+ progestin) oral contraceptives are generally not recommended
for women taking certain antiretroviral medications because
of the potential of each to lessen the effectiveness of the
other medication. Intrauterine devices (IUDs) are often a
good contraceptive option for HIV+ women.
Preconception Care and Pregnancy
The introduction of antiretroviral medications over the last
decade has significantly decreased the rate of mother-to-child
HIV transmission in the US to less than 1%. As more HIV+ women
choose to have children, ob-gyns need to be prepared for detailed
preconception discussions with their patients on how to avoid
transmission of the virus to the baby, their partner, or to
themselves from an HIV+ partner. Transmitting HIV to the baby
can be greatly reduced by taking antiretrovirals during pregnancy
to keep the virus at undetectable levels, by avoiding breastfeeding,
and by giving newborns preventive antiretrovirals for several
weeks after birth.
"Women with HIV can have healthy pregnancies and healthy
babies, but it takes careful planning," said Dr. Jamshidi.
Achieving pregnancy without transmitting the virus to a partner
is best accomplished through artificial insemination instead
of unprotected intercourse. Donor insemination from an HIV-negative
male is the safest option for women who are HIV- but whose
partners are HIV+, according to The College.
Increasing numbers of women with HIV are going through menopause,
according to The College. Studies suggest that the average
age of menopause among HIV+ women is about three to four years
younger than other women. "This may be due to smoking,
drug abuse, and low body weight which are common among women
with HIV," said Dr. Jamshidi. Low bone mass is more prevalent
among HIV+ women nearing menopause, but data to date are lacking
on the treatment of osteoporosis in this subset of women.
Increasing physical activity, stopping smoking, and taking
calcium and vitamin D supplements, however, are standard suggestions
to prevent further bone loss.
Practice Bulletin #117, "Gynecologic Care for Women with
Human Immunodeficiency Virus," is published in the December
2010 issue of Obstetrics & Gynecology.
The American College of Obstetricians and Gynecologists is
the nation's leading group of physicians providing health
care for women. As a private, voluntary, nonprofit membership
organization of approximately 55,000 members, The American
College of Obstetricians and Gynecologists strongly advocates
for quality health care for women, maintains the highest standards
of clinical practice and continuing education of its members,
promotes patient education, and increases awareness among
its members and the public of the changing issues facing women's
American College of Obstetricians and Gynecologists. Practice
Bulletin No. 117: Gynecologic care for women with human immunodeficiency
virus. Obstetrics & Gynecology 116(6): 1492-1509.
College of Obstetricians and Gynecologists. New Focus on Care
for HIV+ Women as More Live Longer with the Disease. Press
release. November 22, 2010.