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Discussion Paper

Women and HIV

April 1998

Gynecologic Concerns and Tests

Gynecologic complications are the most commonly reported condition of women living with HIV disease and AIDS. Complications range from chronic, recurrent yeast infections to abnormal menstrual cycles (periods) to vaginal warts (caused by the human papillomavirus, also called HPV), abnormal results of GYN exams and cervical cancer. Fortunately, many of these can be detected through regular monitoring with pap smears. A pap smear is a test a clinician performs using a cotton swab (like a long Q-tip). During the exam, the clinician inserts this swab and lightly rubs it on your cervix to pick up a sampling of the cells there. Cells are then looked at under a microscope for any abnormalities. A smear that does not show any abnormal cells (which indicate infection or disease of some kind) is called "normal". A pap smear showing any abnormal cells is called "abnormal". An abnormal pap smear tells you something is unusual and then describes the abnormality with one of the following terms listed in Table 2.

Table 2: Abnormal Pap Smear Terms

Term Definition
Atypia These cells show minimal changes. May be "atypical" due to the presence of a vaginal infection, the use of oral contraceptives or because the person doing the Pap smear may have not handled the cells properly.
Dysplasia Means "abnormal development". Dysplasia is a pre-cancerous condition. Dysplasia is described by using CIN 1-3 and CIS to represent the extent of the problem.
SIL SIL stands for Squamous Intraepithelial Lesions. SIL is another way to describe dysplasia by identifying lesions in the thin cellular layers of the vaginal tract. Again, SIL suggests a pre-cancerous condition.
CIN 1 CIN stands for Cervical Intraepithelial Neoplasia. CIN means abnormal growth or tumor in the tissue covering or surrounding the cervix. CIN 1 means that one-third of the sample has dysplasia or pre-cancer.
CIN 2 CIN 2 means 2/3 of the sample has dysplasia.
CIN 3 CIN 3 means that the entire sample shows cells with dysplasia.
CIS CIS stands for Carcinoma-In-Situ. On a Pap smear, this report means the same thing as CIN 3, the entire sample shows dysplasia. However, the sample shows no sign of invasive cancer.

HIV-positive women should have a pap smear performed every six months as long as the results continue to be normal. However, if there is an abnormal pap smear history, the frequency should be increased to once every three months. Once results become normal again, and remain so for three consecutive visits, the frequency can be extended back to once every six months. Abnormal pap smears should be followed by a colposcopy and biopsy to assess the condition. A colposcopy is a clinician's exam done with a lighted microscope to magnify your cervix and take a closer look at any abnormal cells. A biopsy is a small sample cut (in this case, your cervix) to either remove the abnormality or to exam in it for a more thorough diagnosis.

Although it takes consistent effort, it is incredibly important to monitor and treat any infections that may occur. Many women only go to the doctor when something is wrong, but results from one study show that more than 50% of those women who felt nothing was wrong and had no symptoms actually had some type of vaginal tract infection when examined. This means that regular exams are crucial, even when you're feeling well. Both pap smears and colposcopies, as well as breast exams, are designed to pick up early, pre-cancerous activity. Infections such as HPV or genital warts typically don't hurt, so many women do not know they are there. Unfortunately, HPV is sexually transmitted and is believed to be a pre-cancerous condition. If you are diagnosed with HPV, you should be treated and monitored with more frequent pap smears (at least every 3 months).

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Other sexually transmitted diseases (STDs) such as herpes, trichomonas, chlamydia, syphilis and gonorrhea are twice as common in women living with HIV than in HIV-negative women. Unfortunately, the symptoms of many of these infections are the same or similar. This makes routine monitoring and treatment of conditions extremely important when any unusual GYN symptoms are present. Every additional infection the body must fight provides an opportunity for the growth of HIV, and some evidence suggests that secondary infections in the genital area make it easier to spread HIV from one person to the next. This includes sexual partners as well as transmission of HIV from mother-to-infant during labor. This is another reason safer sex is so important. Condom use helps prevent the spread of STD's, including HIV.

Below you will find the Common Gynecologic Infections Chart. This chart has some of the most common infections, symptoms and treatments listed to help you identify possible problems and solutions. It is not meant to take the place of a clinician or an exam. Please use it to help understand what's out there and what you may be experiencing, but always follow up with your health care provider.


Common Gynecologic Infections

Gynecologic (GYN) manifestations are the most commonly reported condition of women living with HIV disease and AIDS. Many of the problems HIV-positive women experience also affect women who are not living with HIV. However, these conditions usually occur more frequently, are more serious and more difficult to treat in a women with a compromised immune system. It is very important that GYN infections be diagnosed, monitored and treated under the guidance of a health care provider.

All infections, including GYN infections, are generally caused by pathogens (disease causing elements). The type of pathogen is an important piece of information. It helps to guide treatment decisions and identify potential complications of that infection. There are four types of infections discussed on the GYN Chart: viral, bacterial, protozoal and fungal. Although there are treatments that can clear symptoms and suppress a virus, there are no cures for viral infections. For example, if you have an herpes outbreak, there are no guarantees that you will not have another or even several more in the future. The treatment merely brings the virus under control and diminishes symptoms, but doesn't make the virus go away. This is different from other types of infections. Bacterial, protozoal and fungal infections can all be cleared from the body, if there is an effective treatment (not all infections have effective treatments). This does not mean that these infections are any less serious. All of these infections can cause serious problems if left untreated.

The Common Gynecologic Infections in Women with HIV Chart is meant to serve as a tool for you to learn more about possible infections, symptoms and treatments so that you can have informed dialogue with your doctor. It does not cover all possible infections, but provides basic information on common ones. The most common sexually transmitted diseases, chlamydia, gonorrhea and syphilis, which can have GYN manifestations, are not included. Many GYN infections may also be systemic diseases (throughout the body, not just in the vaginal tract). Even those listed in the Chart may have such effects.


Pregnancy

For many women, learning of their HIV diagnosis can carry with it the devastating assumption that they can, or will, never have children. Many others receive their diagnosis while pregnant. Over the last several years much has been learned about pregnancy and HIV. Currently, in the United States, about 25% of pregnant women living with HIV who do not use anti-HIV therapies transmit HIV to their infants. That number is considerably smaller (8% or less) for women who do use some type of anti-HIV therapy during pregnancy. In many cities around the U.S., aggressive prenatal care has brought that number even lower. In San Francisco for two years running, not a single child born to an HIV+ woman being cared for through BAPAC (a special program delivering care to HIV+ pregnant women) has been infected with HIV. Although AZT is the most commonly used and the only approved therapy for preventing transmission from mother-to-child, this is largely because it is the only one that has been tested. There are now several other therapies being researched and in common use.

Federal Guidelines for anti-HIV therapy use during pregnancy state that no pregnant woman who seeks it should be denied optimal therapy for her HIV infection. Optimal therapy is characterized as triple combination therapy including at least one potent anti-HIV drug, such as a potent protease inhibitor. All pregnant women should benefit from informed counseling of the potential risks and benefits of using an optimal and potent anti-HIV regimen during pregnancy and then be allowed to make their own decision. Not choosing optimal therapy could possibly limit the mother's options for future therapy. Unfortunately, little is known about the long-term effects of these compounds on the child.

The effects of pregnancy and motherhood on the immune system over the long-term are not entirely known. The vast majority of research in this field has been done in terms of risk to the infant rather than the mother. However, several studies have shown that pregnancy does not speed HIV disease progression. In many cases, a pregnant woman will experience a drop in her CD4+ (T-cell) count while pregnant that returns to her pre-pregnancy level after birth. The new guidelines specifically detail a pregnant woman's right to choose an optimal and potent anti-HIV regimen for her own well-being, as well as her baby's. Perhaps much of the burden here is in external perceptions of a woman's choice to give birth.

Due to so many unanswered questions, any HIV-positive woman who is pregnant or considering pregnancy should seek the care of a clinician with experience and/or knowledge of the latest breakthroughs in HIV research. This insures the best possible prenatal care and the best possible outcome for both mother and child. Please see the resource listing below for additional information and support resources.


Conclusion

Informing yourself is the first step in getting some control over HIV in your life. The more you know, the better able you are to make informed choices about living with HIV disease. There are increasing numbers of women-specific services and support groups on local and national levels. Below you will find a listing of some resources to help you with various types of information and referral to programs. This paper should have helped outline some issues you should consider when making treatment decisions. To talk to someone about your questions or request more information, call the Project Inform Hotline.


Indinavir in Women

reprinted from PI Perspective #24, April, 1998


Little is known about the effects of hormones on the metabolism, potential effectiveness or side effects of drugs in women. A small study looking at the effects of the menstrual cycle on indinavir (Crixivan®) levels in the blood found dramatic differences in time to peak level and time to optimal therapeutic levels based on the various phases of the menstrual cycle over the course of a month. While the amount of indinavir in the blood appeared to change throughout the hormone cycle, it still remained broadly within the ranges observed in earlier studies that primarily included men. These monthly fluctuations need to be further studied to determine their implications on the durability of the regimen, resistance, dosing and possible long-term toxicity. Fortunately, there are several other studies looking at the use of antiretroviral therapy specifically in women, either in development or enrolling, that may have the opportunity to address these questions.


AZT and Mother to Child Transmission

reprinted from PI Perspective #24, April 1998

The reduction in HIV transmission from mother-to-infant with the use of anti-HIV drugs has been a remarkable success story. However, it has not been a reality for many nations where the complexity of the therapy regimen, along with poor access to the necessary drugs, inadequate prenatal care, wide scale malnutrition and the potential for transmission through necessary breast feeding, has blocked the ability to share in this major advance.

Results from a new study in Thailand show the success of a simplified regimen of AZT which reduced by 51% the mother-to-child transmission among women who are not breast feeding (from 18.6% without AZT to 9.2% with AZT). In this study, women were given 300 mg. AZT twice a day orally starting approximately 26 weeks after conception through birth. Unlike the standard US regimen, the babies were not given AZT after birth, nor were the mothers given AZT intravenously during labor. This greatly simplified regimen offers a more viable possibility for women in developing countries, even if it is slightly less efficacious (the US regimen produced a 66% drop in transmission, versus 51% for the simplified regimen.) This simplified AZT regimen will be less costly, potentially allowing many developing nations to implement a useful campaign to reduce mother-to-child transmission of HIV. Further research will need to be done to determine the effectivenes for women who are breast feeding and whether still simpler regimens might be found for women who do not access care until delivery.


Resource List

Project Inform provides an extensive Resource Directory, including national treatment publications, hotlines, web sites and treatment education programs. Call the Hotline for more information! The following are national resources. For local and regional resources, contact your local AIDS service organization.

Women's Programs/Newsletters

Women Alive (213)965-1564 or (800)554-4876, 1566 Burnside Avenue, Los Angeles, CA 90019. Women Alive publishes a quarterly newsletter and is active in policy and treatment issues affecting women living with HIV.

WORLD (Women Organized to Respond to Life-threatening Diseases) (510)986-0340, 414 13th Street, 2nd Floor, Oakland, CA 94612. WORLD publishes a monthly newsletter for women with HIV and has a peer advocate program, a treatment training program called HIV University and several retreats a year for HIV positive women.

Project WISE/WISE WORDS (800)822-7422, 205 13th Street, Suite 2001, San Francisco, CA 94103. WISE WORDS is a monthly treatment newsletter geared to women published by Project Inform, in addition to PI Perspective, a treatment journal. Other services include an advocacy program, town meetings, a treatment hotline and a web-site.

Teens

Bay Area Young Positives (415)487-1616, 518 Waller Street, San Francisco, CA 94117. Bay Positives is a national organization by and for youths living with HIV disease.

Pediatrics

Pediatric AIDS Foundation Trials Hotline (310)395-9051, 1311 Colorado Avenue, Santa Monica, CA 90404. The Pediatric AIDS Foundation advocates on behalf of and funds pediatric research in AIDS. This trial hotline gives listings of studies and provides information for children with HIV/AIDS.

Special Programs for Families

Families' and Children's AIDS Network (312)655-7360, 721 North LaSalle Street, #311, Chicago, IL 60610. Families and Children's AIDS Network provides family support programs, information, and special programs for children.





  
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This article was provided by Project Inform. Visit Project Inform's website to find out more about their activities, publications and services.
 

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