HIV Screening and Women’s Health

Health Care Education & Training, Inc.

Originally developed by:

Section 4:

Gynecological Manifestations of

HIV Infection

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2007 Contributors from AETC Women’s Health and Wellness Workgroup: Joyce Alley, RN; Health Care Education and Training, Inc. Laura Armas, MD; Texas/Oklahoma AETC Andrea Norberg, MS, RN; AETC National Resource Center Tonia Poteat, MPH, MMSc, PA-C; Southeast ATEC

(SEATEC) Barbara Schechtman, MPH; Midwest ATEC (MATEC) Karen Sherman, MA; Health Care Education and Training,

Inc. Jamie Steiger, MPH; AETC National Resource Center

The original curriculum was developed in 2002 by MATEC and Health Care Education & Training, Inc.

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Objective for Section 4:1. Discuss gynecological problems that indicate a

need for HIV screening, including: Vaginal discharge/irritation Abnormal uterine bleeding/amenorrhea Abnormal Pap smear Genital warts Genital ulcers Pelvic/abdominal pain and Pelvic Inflammatory

Disease (PID)

HIV Screening and Women’s Health

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Co-Occurrence of HIV and Gynecologic Disorders

HIV Screening and Women’s Health

41%59%

Women with gynecologic disorder(s) at enrollment

Anogenital warts Syphilis Amenorrhea Symptomatic

candidiasis Oncogenic HPV Abnormal Pap smear

(Minkoff et al., 1999)

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CDC HIV/AIDS Classification System: GYN Manifestations

HIV Screening and Women’s Health

A

Asymp-tomatic

B

HIV-related symptoms

C

AIDS-defining conditions

1.

>500 mm3

(> 29%)

Recurrent Vaginitis Cervical Cancer, invasiveGenital Tract TB

2.

200-499 mm3

(14-28%)

Cervical DysplasiaCervical Carcinoma in situ

Genital Tract Lymphoma

3.

<200 mm3

(<14%)

CMV Endometritis

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Vaginal Discharge/Irritation

HIV Screening and Women’s Health

Women with frequent and/or persistent vaginal discharge should be offered an HIV test

STIs indicate HIV risk behavior and an increased risk for HIV acquisition

Bacterial Vaginosis can increase a woman’s risk of acquiring HIV

Yeast infections are common among women with HIV; therefore, frequent and persistent yeast infections are a cue for HIV testing

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Recurrent Yeast Vaginitis as a Common Presenting Symptom of HIV

HIV Screening and Women’s Health

Prevalence of candiasis among HIV positive women is 3-15%

HIV positive women with CD4 cell counts <200 have significantly increased odds of vaginal or oral colonization of Candida

Recurrent yeast vaginitis is the most common presenting symptom of HIV infection

Credit: Jean R. Anderson, MD

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Abnormal Uterine Bleeding

HIV Screening and Women’s Health

Abnormal uterine bleeding/menstrual disorders are very common among HIV positive women

Bleeding may not be due to HIV disease, but possibly to related factors such as: Weight loss Chronic disease Substance abuse Use of progesterone (for appetite stimulation or

contraception)

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Abnormal Pap Smear

HIV Screening and Women’s Health

30-60% of Pap smears from HIV positive women have cytological abnormalities (Larkin et al., 1999)

15-40% of these Pap smears exhibit dysplasia (Larkin et al., 1999)

Women with HIV are more likely to have persistence of HPV and cervical dysplasia

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Abnormal Pap Smears in HIV Positive Women

Genital Tract Neoplasia

HIV Screening and Women’s Health

Pap Smear Screening - WIHS Cohortfollowed for 3.5 years

Cumulative RiskHIV + HIV -

Benign 33% 67%Ascus 28% 23%LGSIL 34% 8%HGSIL 5% 3%Cancer 0.4% 0%

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Cervical Neoplasia

HIV Screening and Women’s Health

Cervical cancer is an AIDS defining illness In a study of 2,015 HIV-infected women and 577

seronegative controls, 58% of HIV- infected women had HPV as compared with the seronegative controls of 26%

In HIV positive women, dysplasia is associated with more extensive cervical involvement and is more likely to involve other sites in the lower genital tract

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HPV as a Common Presenting Symptom of HIV

HIV Screening and Women’s Health

Before Treatment After Treatment

Credit: Cliggott Publishing

Credit: Cliggott Publishing

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Genital Ulcers

Diseases which present with genital ulcers and may be associated with HIV disease include: herpes, syphilis, chancroid, cytomegalovirus, lymphogranuloma venereum, granuloma inguinale, and tuberculosis

Women with HIV often experience more severe manifestations of these diseases due to immunosuppression

Genital ulcers serve as a portal of entry for HIV; thus women affected by such ulcers are at a greater risk of infection

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Pelvic/Abdominal Pain

HIV Screening and Women’s Health

Pelvic inflammatory disease (PID) or pregnancy are common causes of pelvic pain

Many studies have shown an increased prevalence of HIV in hospitalized PID patients, indicating that providers should offer women with PID an HIV test

All pregnant women should be offered an HIV test, as part of routine prenatal care

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Resources AIDS Education and Training Centers

www.aidsetc.org Cervical Cancer Screening and the HIV-Infected Woman slide set Human Papillomavirus and the HIV-Infected Woman slide set Common Sexually Transmitted Diseases and the HIV-Infected

Woman slide set Title X Family Planning Regional Training Centers

http://opa.osophs.dhhs.gov/titlex/ofp-training-grantees-listing.html

Health Resources and Services Administration, HIV/AIDS Bureau http://hab.hrsa.gov/publications/womencare05/index.htm A Guide to the Clinical Care of Women with HIV, 2005 edition, Ed.

Jean R. Anderson

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References Ahdieh, L., Klein, R.S., Burk, R., Cu-Uvin, S., Schuman, P., Duerr, A., Safaeian, M., Astemburski, J.,

Daniel, R., & Shah, K. (2001). Prevalence, incidence, and type-specific persistence of human papillomavirus in human immunodeficiency virus (HIV)-positive and HIV-negative women. Journal of Infectious Diseases, 184: 682–690.

Ahdieh, L., Munoz, A., Vlahov, D., Trimble, C., Timpson, L., & Shah, K. (2000). Cervical neoplasia and repeated positivity of human papillomavirus infection in human immunodeficiency virus-seropositive and -seronegative women. American Journal of Epidemiology, 151: 1148–1157.

American Society For Colposcopy and Cervical Pathology. Consensus Guidelines. Retrieved on August 6, 2007 from http://www.asccp.org/

Anderson, J.R., ed. (2005). A Guide to the Clinical Care of Women with HIV. Health Resources and Services Administration HIV/AIDS Bureau.

Branca, M., Garbuglia, A.R., Benedetto, A., Cappiello, T., Leoncini, L., Migliore, G., Agarossi, A., & Syrjanen, K. (2003). Factors predicting the persistence of genital human papillomavirus infections and Pap smear abnormality in HIV-positive and HIV-negative women during prospective follow-up. International Journal of STDs & AIDS, 14: 417–425.

Centers for Disease Control and Prevention. 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults. MMWR, December 18, 1992, 41 (RR-17).

Centers for Disease Control and Prevention. (2004). Bacterial Vaginosis Fact Sheet. Retrieved on August 6, 2007 from http://www.cdc.gov/std/bv/STDFact-Bacterial-Vaginosis.htm

Centers for Disease Control and Prevention. Sexually Transmitted Diseases Guidelines 2006. Retrieved on August 6, 2007 from http://www.cdc.gov/std/treatment/

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References (continued) Evander, M., Edlund, K., Gustafsson, A., Jonsson, M., Karlsson, R., Rylander, E., & Wadell, G.

(1995) Human papillomavirus infection is transient in young women: a population-based cohort study. Journal of Infectious Diseases, 171: 1026–1030.

Feingold A.R., Vermund, S.H., Burk, R.D., Kelley, K.F., Schrager, L.K., Schreiber, K., Munk, G., Friedland, G.H., & Klein, R.S. (1990). Cervical cytologic abnormalities and papillomavirus in women infected with human immunodeficiency virus. Journal of Acquired Immune Deficiency Syndromes. 3(9): 896-903.

Garcia, P.M. & Sha, B.E. (2000) Women and HIV: Continuing the Challenge. Retrieved on August 6, 2007 from http://www.medscape.com/viewprogram/621

Grulich, A.E., Li, Y., Correll, P., McDonald, A., & Kaldor, J.M. (2000) National linkage of HIV, AIDS and cancer incidence data. 4th International AIDS Malignancy Conference. Journal of Acquired Immune Deficiency Syndromes, 23: A15 (abstract 1).

Heard, I., Tassie, J.M., Schmitz, V., Mandelbrot, L., Kazatchkine, M.D., & Orth, G. (2000). Increased risk of cervical disease among human immuodeficiency virus-infected women with severe immunosuppression and high human papillomavirus load. Obstetrics & Gynecology, 96: 403–409.

Hillemanns, P., Ellerbrock, T.V., McPhillips, S., Dole, P., Alperstein, S., Johnson, D., Sun, X.W., Chiasson, M.A., & Wright, T.C. (1996). Prevalence of anal cytologic abnormalities and anal human papillomavirus infections in HIV-seropositive women. AIDS, 10: 1641–1647.

Ho, G.H., Bierman, R., Beardsley, L., Chang, C.J., & Burk, R.D. (1998). Natural history of cervicovaginal papillomavirus infection in young women. New England Journal of Medicine, 338: 423–428.

Holly, E.A., Ralston, M.L., Darragh, T.M., Greenblatt, R.M., Jay, N., & Palefsky, J.M. (2001). Prevalence and risk factors for anal squamous intraepithelial lesions in women. Journal of the National Cancer Institute, 93: 843–849.

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References (continued)Jamieson, D.J., Duerr, A., Burk, R., Klein, R.S., Cu-Uvins, S., Paramsothy, P. Shah, K., & Schuman,

P. (2002). HIV Epidemiology Research Study (HERS). Characterization of genital human papillomavirus infection in women who have or who are at risk of having HIV infection. American Journal of Obstetrics & Gynecology, 186: 21–27.

Kiviat, N.B., Critchlow, C.W., Holmes, K.K., Kuypers, J., Sayer, J., & Dunphy, C. (1993). Association of anal dysplasia and human papillomavirus with immunosuppression and HIV infection among homosexual men. AIDS, 7: 43–49.

Korn, A.P. & Landers, D.V. (1995). Gynecologic disease in women infected with human immunodeficiency virus type 1. Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology. 9 (4): 361-70.

Lacey, H.B., Wilson, G.E., & Tilston, P. (1999). A study of anal intraepithelial neoplasia in HIV-positive homosexual men. Sexually Transmitted Infections, 75: 172–177.

Larkin, J.A., Minerva, K., Hold, D., & Nadler, J. (1999). Women and HIV: When to Test? AIDS Reader, 9 (3): 175-183.

Luque, A.E., Demeter, L.M., & Reichman, R.C. (1999). Association of human papillomavirus infection and disease with magnitude of human immunodeficiency virus type 1 (HIV-1) RNA plasma level among women with HIV-1 infection. Journal of Infectious Diseases, 179: 1405–1409.

Maiman, M., Fruchter, R.G., Serur, E., Remy, J.C., Feuer, G., & Boyce, J. (1990). Human immunodeficiency virus infection and cervical neoplasia. Gynecological Oncology, 38: 377–382.

Massoud et al. (2000). Conf Retroviruses and Opportunistic Infections (abstract 675).Minkoff H.L., Eisenberger-Matityahu, D., Feldman, J., Burk, R., & Clarke, L. (1999). Prevalence and

incidence of gynecologic disorders among women infected with human immunodeficiency virus. American Journal of Obstetrics & Gynecology, 180: 824–836.

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References (continued) Minkoff, H., Feldman, J., DeHovitz, J., Landesman, S., & Burk, R. (1998). A longitudinal study of

human papillomavirus carriage in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women. American Journal of Obstetrics & Gynecology, 178: 982–986.

Palefsky, J.M., Holly, E.A., Hogeboom, C.J., Berry, J.M., Jay, N., & Darragh, T.M. (1997) Anal cytology as a screening tool for anal squamous intraepithelial lesions. Journal of Acquired Immune Deficiency Syndromes ,14: 415–422.

Palefsky, J.M., Holly, E.A., Ralston, M.L., Da Costa, M., & Greenblatt, R.M. (2001a). Prevalence and risk factors for anal human papillomavirus infection in human immunodeficiency virus (HIV)-positive and high-risk HIV-negative women. Journal of Infectious Diseases, 183: 383–391.

Palefsky, J.M., Minkoff, H., Kalish, L.A., Levine, A., Sacks, H.S., Garcia, P., Young, M., Melnick, S., Miotti, P., & Burk, R. (1999). Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high risk HIV-negative women. Journal of the National Cancer Institute, 91: 226–236.

Petry, K.U., Kochel, H., Bode, U., Schedel, I., Niesert, S., Glaubitz, M., Maschek, H., & Kuhnle, H. (1996). Human papillomavirus is associated with the frequent detection of warty and basaloid high-grade neoplasia of the vulva and cervical neoplasia among immunocompromised women. Gynecologic Oncology, 60: 30–34.

Schuman, P., Ohmit, S.E., Vazquez, J., Klein, R.S., Mayer, K., Rompalo, A., Jamieson, D., & Sobel, J.D. (2000). Longitudinal assessments of oral and vaginal candida colonization, species, and fluconazole susceptibility in HIV-seropositive women. The HER study. Conf Retroviruses Opportunistic Infect 2000 Jan 30-Feb 2; 7:202 (abstract no. 676)

Sun, X.W., Ellerbrock, T.V., Lungu, O., Chiasson, M.A., Bush, T.J., & Wright, T.C. (1995). Human papillomavirus infection in HIV-seropositive women. Obstetrics & Gynecology, 85: 680–686.

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References (continued) Sun, X.W., Kuhn, L., Ellerbrock, T.V., Chiasson, M.A., Bush, T.J., & Wright, T.C. (1997). Human

papillomavirus infection in women infected with the human immunodeficiency virus. New England Journal of Medicine, 337: 1343–1349.

The AIDS Reader. (2000). Genital Warts in HIV. Retrieved on January 2, 2008 from http://www.medscape.com/viewarticle/410246_5

Uberti-Foppa, C., Origoni, M., Maillard, M., Ferrari, D., Cuiffreda, D., Mastrorilli, E., Lassarin, A., & Lillo, F. (1998). Evaluation of the detection of human papillomavirus genotypes in cervical specimens by hybrid capture as screening for precancerous lesions in HIV-positive women. Journal of Medical Virology, 56: 133–137.

Williams, A., Darragh, T.M., Vranizan, K., Ochia, C., Moss, A.R., & Palefsky, J.M. (1994). Anal and cervical human papillomavirus infection and risk of anal and cervical epithelial abnormalities in human immunodeficiency virus-infected women. Obstetrics & Gynecology, 83: 205–211.

HIV Screening and Women’s Health