This Month in HIV: State-of-the-Art: Women and HIV/AIDS
Cathy, I wondered if you would talk to the first part of what Dr. Cohen said, which is some of the tests that women with HIV should be getting on a regular basis, and some of the vaccines that they should be getting? Did you have anything else on your list?
Cathy Olufs: Well, we know that the HPV vaccine is available, although I would imagine that most women who are already HIV infected have probably been exposed to HPV at some point in their life, so we're not really sure how effective that vaccine would be. However, there are increasing reports of women coming up with anal cancers associated with HPV infections. As women, we grow up learning to wipe front to back. If a woman has HPV it can very easily be transmitted to the anal area. So it's important for women to be screened for anal cancers, as well.
So they should get an anal Pap smear?
Cathy Olufs: Exactly. A lot of women would probably be embarrassed to have their provider perform an anal Pap, but I think it's really, really important. Because I know there were some reports at CROI this year, the retrovirus conference, showing that cancers -- non-HIV-associated cancers -- are actually increasing in people with HIV, including anal cancers. So I think it's important for women to be screened for that, whether or not they have ever had anal sex. That's not necessarily an issue.
Where would one find an HIV-experienced gynecological care clinic?
Cathy Olufs: You can ask around in your community. I think it's important to interview the physician who is going to be treating you, to ask what their experience is. Are they affiliated with any one of the HIV medical associations? [The two major medical associations for HIV specialists are the American Academy of HIV Medicine and the HIV Medicine Association.] Do they keep up on the latest information? Do they attend the conferences?
Do HIV specialists refer patients to gynecologists experienced with HIV?
Cathy Olufs: Yes. That's been my experience. Whenever I've needed gynecological care, my treating physician usually will refer me to someone who they are familiar with, that's also familiar with treating HIV. Because it's crucial.
Dr. Mardge Cohen: This is an important area for this patient-doctor partnership, because if a woman is not clear that gynecological issues are important in women with HIV and the HIV providers are going through all their stuff and not attending to that, then they're going to miss a very important area. If the patient is not going to a gynecologist in addition to the HIV provider, then she won't have an opportunity to get a Pap smear and discuss these issues, ensure that these issues are addressed.
Some groups have thought about a card for women with HIV, which are the things that they have to sort of check off on the list, to make sure they're getting the best care. I think getting a Pap smear that someone looks at, that someone understands in the context of HIV, is a good starting point for that card.
A very important point. Is it in the guidelines now, particular care for women with HIV?
Dr. Mardge Cohen: Yes. It's very important. Someone could say, "Oh, make sure you get one." I'm not sure every HIV physician is doing gynecological exams. Some are, and that's good. Some will refer, and then have someone else do it. But it is an issue for women, that women have to name as an issue, that should be addressed -- just as contraception, just as having children, etc.
Dr. Cohen, I have one more question. You have mentioned hepatitis C. I think there are a lot of misconceptions about this. A lot of women think that they have already been tested for it. They think, "Well, I got tested for HIV and other STDs, so I must have gotten tested for that." Or they already got their initial care for HIV, so they think, "Well, they probably looked if I had that, too."
Dr. Mardge Cohen: Again, this is a routine, expected guideline, that people with HIV should have their status, in terms of hepatitis A, B, and C checked, to know whether they are immune to A and B, or have been infected at some point with hepatitis C, and would require further investigations. A lot of people clear hepatitis C. For a lot of people, it's not a problem.
Increasingly, it's a very important disease entity for women and men with HIV to understand, to take seriously. People are living longer with HIV; therefore, we don't want them to die from other causes. We want them to get the best treatment for other diseases that they have, now that their HIV is under significant control.
I think, between patients going to different providers and a poor health care information system, a lack of a national health care program, health care is not as good as it should be. I think people understanding and having a list in their heads of what the diseases are that they have to make sure they have been evaluated for is the best way to ensure this.
So you would recommend that if a woman doesn't know if she's been tested ...
Dr. Mardge Cohen: She should find out, right. I definitely would suggest that she should know.
You go with a checklist.
"We need patients and doctors partnering. Sometimes the best way to do that is for patients to remind doctors, and sometimes it's for doctors to ensure that they have all this available information so that they are reminded to do the right thing all the time."
-- Dr. Mardge Cohen
Dr. Mardge Cohen: I think that's the best way. In general, patients in whatever disease they have feel at a disadvantage because they don't know everything and often physicians and patients don't partner to deal with a disease. That's what we most need in order to make HIV and every other medical problem get the best resolutions. We need patients and doctors partnering. Sometimes the best way to do that is for patients to remind doctors, and sometimes it's for doctors to ensure that they have all this available information so that they are reminded to do the right thing all the time. I think both working together is really the best way to make that happen.
Cathy, do you remind your doctor to do things?
Cathy Olufs: Actually, I'm very lucky. I have a great physician. She's one of the top female HIV physicians in the country. So I feel blessed, in that quite often we have some very interesting discussions about treatment, but I haven't ever found myself needing to remind her. It's usually quite the opposite. She'll remind me, "It's time for your Pap," or something like that. But we have a great relationship. I think that's crucial, as well -- that you have open lines of communication with your physician. If you feel at all uncomfortable with the physician that you're seeing, it is within your right to request to be seen by a different doctor.
Were you always so brave?
Cathy Olufs: No. Absolutely not. It came with time and listening to other women and taking the advice of other people to stand up for myself and stand up for my health.
How did you find your doctor?
Cathy Olufs: Well, I ended up at the clinic where I'm at right now through the form of health insurance that I have. But I actually saw my doctor's name in print long before that, in relation to HIV research studies for women.
So you picked a researcher who was also treating?
Cathy Olufs: Yes. I got lucky. When I went to the clinic, I requested to see her and she was available. So I'm pleased about that. I've never really had a bad experience with a physician, but I've had some uncomfortable experiences with some physicians over the years. But never really a bad experience. I think most physicians that are in this work truly, truly care about what they're doing. There are many different opportunities that they can be involved with, as far as medical care. If they have chosen to be involved with HIV, I feel like there's an extra special commitment there.
Dr. Cohen, in your previous answer, you mentioned women who want to have a baby. Could you go into that a little bit? What if a woman is thinking about having a baby? What kinds of things should she take into consideration?
Dr. Mardge Cohen: It should be brought to the table, and a woman should feel empowered to have that discussion. We want to ensure that she goes about that in the healthiest way for her and everybody else involved.
That would require a very sympathetic and knowledgeable obstetrics team that is committed to using medications and treating her throughout the entire pregnancy, and monitoring well, and following at labor and delivery and postpartum.
The idea that I was referring to is that this is a serious desire on many women's parts, and it should be met. Women who know they are infected with HIV are becoming pregnant and are doing well during their pregnancy. It doesn't increase disease progression of HIV. It's pretty much all good news for women who are doing well on antiretrovirals, or who are early in the course of illness, to proceed appropriately to have a child.
"Women who know they are infected with HIV are becoming pregnant and are doing well during their pregnancy. It doesn't increase disease progression of HIV. It's pretty much all good news for women who are doing well on antiretrovirals, or who are early in the course of illness, to proceed appropriately to have a child."
-- Dr. Mardge Cohen
We discourage the use of efavirenz or Sustiva [Stocrin] in women who are thinking about getting pregnant. We would recommend different medications. But there is a whole host [of options], and there are good choices and great results, in our country, for women who are HIV infected and know it, who desire to have a child.
It's a really important issue to state: Women with HIV can make these reproductive choices. I say this because of the history of HIV care in women. Women were more often discriminated against. If they wanted to have children, they weren't taken seriously. It wasn't thought to be appropriate. That's really changed today, and it should continue to change, so that women can have the right to the reproductive choices that they want.
Would you say this is true for women at any CD4 count? Or is there some cutoff point?
Dr. Mardge Cohen: The woman makes the decision, basically. I've seen women at every CD4 count have children. Sometimes there weren't exact choices being made. Things just sort of happened. But right now, we have the potential to have women improve their CD4 count. So therefore, there can be a discussion of, "Well, maybe it would be better for your situation, for you and for what you want to do in the future, to see how you respond to HAART therapy, to antiretroviral therapy. When we see you're doing well, that will be a better opportunity to think about getting pregnant."
But to make sure that it's a discussable point, and that you feel comfortable talking about it with the provider, and the provider feels comfortable talking about it with you. Otherwise, you're going to get mixed messages.
Cathy Olufs: I agree. You hit on a really important point about making sure that you discuss your desire to get pregnant with your physician, hopefully prior to actually becoming pregnant. There are a lot of things that women can do to bolster their health prior to actually achieving a pregnancy, which will help support a healthy pregnancy and a healthy outcome.
So whenever possible let your physician know that you're considering this. There are vitamins that you can take and we know that it's very important for a woman to have a low viral load going into a pregnancy, as well as a low viral load during pregnancy and delivery. So, again, whenever possible, it's great to plan a pregnancy, and it's such fabulous news for women living with HIV, at least in the developed world, that we can have that option now and be relatively safe.
Does a woman have to be on HIV treatment?
Dr. Mardge Cohen: Yes. When she's pregnant?
Dr. Mardge Cohen: We recommend it, actually, regardless of her CD4 count, in order to reduce transmission of the virus. It's, of course, always the woman's choice, what she wants to do. The recommendation is not only to reduce the viral load and increase CD4, but to reduce the risk of HIV transmission during pregnancy. Being on HIV medications is believed to be quite important.
Pregnancy is also a time to discuss other issues that are important, actually, during many parts of a woman's life. Cigarette smoking, alcohol, drug use, violence issues are also important to consider for a healthier time with HIV, as well as, for sure, to maintain the best pregnancy.
In terms of breastfeeding, I know there was recent news from the big HIV conference in Los Angeles about breastfeeding in the developing world. Could you talk to what this means for women in the U.S.A.?
Dr. Mardge Cohen: I think the recommendation is going to stay the same in our country: for women with HIV to not breastfeed. There is an increase in HIV infection with each month of breastfeeding. I think what we saw in the study that was done in South Africa by really wonderful people is that other issues of mortality in the developing world do weigh in. Breastfeeding itself for the first six months solely -- solely breastfeeding -- was the most effective way, compared to supplementation or mixed feeding [to reduce infant mortality]. That's not the situation we have in our country. I think I'm not convinced that our guidelines are going to change soon.
Whatever was recommended and is being recommended now ... nothing should change as a result of that conference?
Cathy Olufs: I agree that there were clear indications, that there are special issues in some of the countries in the studies ... poor sanitation, problems with unclean water to mix the formula. We don't have those issues here. I think there are other options for women in the U.S. who may want to be able to provide breast milk to their infant. There are programs where women can share breast milk. So maybe if you have the resources, you could obtain breast milk through one of those sources, rather than putting your child at risk if you're HIV positive.
What if you don't want to get pregnant? What are the contraceptives that you can use, if you're on treatment?
Dr. Mardge Cohen: The information on the difficulties related to birth control with hormonal contraception in women with HIV is hard to interpret, in my opinion. So that really, it's whatever regimen the woman and her provider finds to be the best for her. ... We have women on things that they've chosen -- whether that's Depo-Provera, or whether that's other approaches. The thing to, of course, remember is that anything that is contraception, that prevents a woman from getting pregnant, if not a condom, will not, of course, prevent another infection with HIV. Though the data's a little unclear on that, as well, I think reinfection is not a good thing.
Do you think HIV medications lower the effectiveness of hormonal birth control pills?
Cathy Olufs: I think there's enough data out there to know that a woman who is taking hormonal contraceptives definitely needs to have her drug levels monitored, to make sure that she's not either losing effectiveness of either the contraceptive itself or the protease inhibitor, or the HIV medication that she happens to be on. There's a lot of data that shows that either the meds impacted the contraceptive, or the contraceptive impacts the meds. I think if a woman really does not want to take any risk of becoming pregnant that she might consider using a second barrier method of contraception ... just in case.
I know that there's a push for further studies to actually find out what the impact is of some of the newer medications, and even the ones that we have, on hormonal contraceptives. This is one of the many, many still-unanswered questions in relation to HIV treatment for women. We get little bits and pieces each year. Maybe a small study comes out with a little more information. I think we still don't know everything we need to know.
Are there any gender differences, in terms of responsiveness to treatment, that you've noticed? I know there have not been that many studies yet. But what do we know so far. Anything? Dr. Cohen?
Dr. Mardge Cohen: Well, there are some studies that have shown that there's a greater viral rebound in women when they stop certain medications. There are some studies that show that, just starting with women versus men, that women's viral load at any particular CD4 count is lower than a man's viral load at that same CD4 count. But much of what we know along those lines has not produced a clinical significance at this point.
We think that the reasons for these changes -- I'll get to side effects in a second -- but we think the reasons for this might be hormonal, might be fat distribution. There are lots of really important areas to continue to investigate.
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This article was provided by TheBody. It is a part of the publication This Month in HIV.
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